Zero Attempts

One Million & Counting
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Life Journeys: Reclaiming Life After Loss

What is "Zero Suicide?"

Why plans to achieve zero suicides might actually be counterproductive

100,000 adolescents and young adults in the United States experience FEP each year
What is "Zero Attempts?"

One Million & Counting. Do the math
Attempters’ Longterm Survival
Suicide statistics
Suicide Facts
Youth Suicide Statistics
Suicide: Statistics, Warning Signs and Prevention
No suicide attempt should be dismissed or treated lightly
Suicide often not preceded by warnings
The Six Reasons People Attempt Suicide

Zero Suicide is an International Movement.
What Happens If You Try To Prevent Every Single Suicide?
An open-minded, skeptical look at the success of “zero suicides”: Any evidence beyond the rhetoric?
Therapy Prevents Repeat Suicide Attempts
KidsHealth on the Topic of Suicide 

Suicide Survivor Day 11/18/17 - Oregon Events
Watch the films — and our previous Survivor Day films — here.

Common Language
Zero Suicide Attempts Trainings
Quick Guide to Getting Started with Zero Suicide
Zero Suicide Organizational Self-Study - 21 page pdf
A multi-source collection of readings, tools, videos, and webinars to help you understand and implement Zero Suicide
A multi-source collection of readings, tools, videos, and webinars to help you understand and implement Zero Suicide
Zero Suicide Academy
Zero suicide toolkit
Newer Developments in ED Operations and Alternatives - 28 page PDF
2015 National Behavioral Health Conference - 38 page PDF
Adolescent Suicidal Behavior: Evaluation and Treatment Conditions 109 page PDF

 Important Statistics

Suicide 1990-2023. (See
Oregon Causes of Death by Age & Gender
Suicides is leading cause of death for 15-54 year old Oregonians - more age categories that any other state.
Curry County leads all 36 counties in Oregon in suicides per capita. (See )


What is Zero Suicide?

ZERO Suicide is an initiative launched by the National Action Alliance for Suicide Prevention and it is a product of the Education Development Center is a commitment to suicide prevention in health and behavioral health care systems.

Zero Suicide is a key concept of the 2012 National Strategy for Suicide Prevention, a priority of the National Action Alliance for Suicide Prevention (Action Alliance), a project of Education Development Center's Suicide Prevention Resource Center (SPRC), and supported by the Substance Abuse and Mental Health Services Administration (SAMHSA). The foundational belief of Zero Suicide is that suicide deaths for individuals under care within health and behavioral health systems are preventable. It presents both a bold goal and an aspirational challenge.

For health care systems, this approach represents a commitment:

» To patient safety, the most fundamental responsibility of health care

» To the safety and support of clinical staff, who do the demanding work of treating and supporting suicidal patients

The programmatic approach of Zero Suicide is based on the realization that suicidal individuals often fall through the cracks in a sometimes fragmented and distracted health care system. A systematic approach to quality improvement in these settings is both available and necessary.

The challenge and implementation of Zero Suicide cannot be borne solely by the practitioners providing clinical care. Zero Suicide requires a system-wide approach to improve outcomes and close gaps.

Essential Elements of Suicide Care

After researching successful approaches to suicide reduction, the Action Alliance’s Clinical Care and Intervention Task Force identified seven essential elements of suicide care for health and behavioral health care systems to adopt:

  • Lead – Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care. Include survivors of suicide attempts and suicide loss in leadership and planning roles.
  • Train – Develop a competent, confident, and caring workforce.
  • Identify – Systematically identify and assess suicide risk among people receiving care.
  • Engage – Ensure every individual has a pathway to care that is both timely and adequate to meet his or her needs. Include collaborative safety planning and restriction of lethal means.
  • Treat – Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors.
  • Transition – Provide continuous contact and support, especially after acute care.
  • Improve – Apply a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk.

Zero Suicide is a call to relentlessly pursue a reduction in suicide and improve the care for those who seek help.

Why plans to achieve zero suicides might actually be counterproductive

"ZERO suicide” is the phrase of the moment in mental health. Thanks to a programme in Detroit that managed to push rates of suicide to zero within a few years, the approach has spread to health bodies all over the world. Last week, the UK government appointed England’s first minister for suicide prevention, on the back of a “zero suicide ambition” for patients in the care of the National Health Service announced in January. Reducing the number of suicides is clearly a desirable goal. Yet some doctors view the zero suicide movement with alarm, fearing that such a …(Editorial Note:This is from NewScientist which requires a susbscription to read further. However, we wanted to note the opposing view that is out there. No indication whether the view has been peer reviewed or it's possibly a view to get the behaviorial health communitty off their backs . Behavioral Health advocates have long challenged ER and GPs to "Ask the Questions" of every patient at the end of an appointment since 90% of those who die by suicide had a visit with their GP within a yaer of the suicide and 45% within 30 days.)


One Million & Counting. Do the math

Why Zero Attempts versus Zero Suicide?

There were 48,344 suicides in 2015. If we were to assume that there are 25 attempts for every successful suicide, then there were 1,208,600 attempts plus 44,193 successful suicides for a total of 1,149,018.. It is further said that 60% of the successful suicides had contact with a mnetal health professional in the 30 days before the suicide.

If we are to hope to get anywhere near Zero Suicides, much less Zero Attempts, we must (1) Teach as many people to know the signs of suicide risk as know how to do CPR, (2) Determine why we have been unable to stop the majority of suicides, particularly after they have had contact with a mentl health professional, (3)

The psycological community says that suicide is preventable but something's not working?

Not only the cost but the incredable harm that is done not only to the vitims but for those around them and speaeding out, as a shock wave, to hundreds of others as a result of every one of those attempts.

Each attempt impacts at least 100 people.

Under Construction

Zero Suicide is an International Movement

Suicide is a complex, multi-faceted, biological, psychological and societal problem with limited prevention resources. Zero Suicide is a global movement that has called upon and joined together suicide prevention experts from across the globe; to research, evaluate and share prevention successes. The result is continuous improvement and dissemination of tools and instructions for health care professionals, equipping them for effective and caring interactions with those experiencing the despair of suicidal thoughts. The movement is based upon a foundational belief that suicide deaths are preventable.

What Zero Suicide Does Not Mean

Zero Suicide is NOT a zero tolerance approach. Clinical professionals often carry a heavy burden related to suicide, and the Zero Suicide movement is intended to empower them in their efforts to aid others, not to shame them or increase their loads. Similarly, the Zero Suicide movement exists to support those experiencing suicidal thoughts, freeing them from the shame and stigma that surrounds suicide and giving them voice, while helping them find purpose in life.

Rediscovering Hope

Zero Suicide reflects a commitment by healthcare leaders to strive to make suicide a “never” event, so that not one person dies alone and in despair. To achieve this goal, a culture must be cultivated where caring, confident and competent staff are supported to continuously improve and learn together. Patients are encouraged to rediscover hope and find ways to survive (and thrive) so that they can reengage with–and contribute to–the communities in which they work, play and live.

First Break Psychosis

  • 100,000 adolescents and young adults in the United States experience FEP each year
  • Onset between 15-25 years of age,
  • Initiate a trajectory of accumulating disability
  • Early intervention with evidence-based therapies offers real hope for clinical and functional recovery
  • Annual cost of schizophrenia over $70 Billion
  • Frequent visitors to Emergency CareRA1SE


What is Zero Attempts?

Basically the same concept as Zero Suicides but goes one step deeper. Taking steps to prevention suicides BEFORE the person enters the health care system starting with stigma, ideation, planning, and attempts..

Last year it is projected that:

8.3 million adults had serious thought of committing suicide
2.3 million made suicide plans
1.1 milloin attempted suicide
0.9 million made plans and attempted suicide
0.2 million made no plans and attempted suicide

48,344 succeeded in 2018

It is estimated that there are 25 attempts for every suicide. In 2011, there were 42 Emergency Room visits for every successful suicide. If we can create a culture that has Zero Attempts, we will automatically have Zero Suicides and much less pain and suffering that is involved with those attempts.

What Happens If You Try To Prevent Every Single Suicide?

Each year, nearly three times as many Americans die from suicide as from homicide. More Americans kill themselves than die from breast cancer.

As Dr.Thomas Insel, longtime head of the National Institute of Mental Health, prepared to step down from his job in October, he cited the lack of progress in reducing the number of suicides as his biggest disappointment. While the homicide rate in the U.S. has dropped 50 percent since the early 1990s, the suicide rate is higher than it was a decade ago.

"That to me is unacceptable," Insel says.

It hasn't been for lack of trying. The U.S. has a national suicide hotline, and there are suicide prevention programs in every state. There's screening, educational programs, and midnight walks to raise awareness. Yet over the past decade or so, the national suicide rate has increased. In 2003, the suicide rate was 10.8 per 100,000 people. In 2013, it was 12.6.

An effort that began in Detroit in 2001 to treat the most common cause of suicide — depression — is offering hope. With a relentless focus on finding and treating people with depression, the Henry Ford Health System has cut the suicide rate among the people in its insurance plan dramatically. The story of the health system's success is a story of persistence, confidence, hope and a strict adherence to a very specific approach.

That approach saved the life of a woman who prefers to be known only by her first name, Lynn. She agreed to share her medical history on the condition that we not use her full name to protect her privacy.

Lynn, who's now in her mid-50s, has had bipolar disorder, also known as manic-depressive illness, for nearly 30 years. The depressive part of her illness "is like the pain of having a cancer," she says. About 15 years ago, she started getting irresistible urges to take her own life and she started making serious attempts — at times almost monthly.

"When I was in the depths of depression, I was being pulled and sucked into this black tunnel," she says. "I was desperately trying to grab onto something to stop from being sucked in." Sometimes she couldn't find anything to hang on to. "Those are the times when I finally let go and attempted suicide," she says.

The program that saved Lynn almost didn't get off the ground.

Fifteen years ago, suicide prevention care at Henry Ford, like in many places, was mostly reactive. When patients came in talking about suicide, health providers took notice. But little was done to find people before they reached that point.

Some of the health providers in the psychiatric division decided they could do better. So they applied to a foundation for a grant to provide something they called "perfect depression care" for the 200,000 patients in the health system. The goal: zero suicides.

The mental health division failed to win the grant, but the health system went ahead with the proposed changes anyway.

The plan it developed is intensive and thorough, an almost cookbook approach. Primary care doctors screen every patient with two questions: How often have you felt down in the past two weeks? And how often have you felt little pleasure in doing things? A high score leads to more questions about sleep disturbances, changes in appetite, thoughts of hurting oneself. All patients are questioned on every visit.

If the health providers recognize a mental health problem, patients are assigned to appropriate care — cognitive behavioral therapy, drugs, group counseling, or hospitalization if necessary. On each patient's medical record, providers have to attest to having done the screening, and they record plans for any needed care.

Therapists involve patients' families, and ask them to remove guns or other means of suicide from their homes. Clerks are trained to make sure that patients who need followup care don't leave without an appointment. Patients themselves come up with "safety plans."

Lynn has two copies, one by her nightstand and one in her kitchen. Each lists things she can do when she feels depression coming on. She could sit on her balcony, or do some drawing or painting. The list includes her therapists' phone numbers. And there's a reminder that the feeling will pass — it has before.

Before the zero suicide plan went into effect, says psychiatrist Doree Ann Espiritu, acting head of the zero suicide program at Henry Ford, you might make a contract with a patient where the patient agrees not to commit suicide. Studies show it doesn't work very well, she says.

Today, providers are trained to be comfortable asking their patients about suicidal thoughts. "There is a fear among clinicians that if you ask questions about suicide, you are giving the patient an idea that this could be an option," says Espiritu, "and if you ask about guns or pills, that you are giving them some hints on how they can carry out a plan." The Henry Ford therapists are trained to break that barrier.

For Lynn, the key was persistence — her therapists', and her own. "I recall one time with my psychiatrist, who kept trying to encourage me and help me find ways of coping, and I can remember saying, 'I don't believe there's hope, I don't see it, I don't feel it, I need you to hold on to that for me because it's not there,' " she recalls.

Her therapists never gave up. "There is no question that the message I got from Day 1 is that they knew they could help me, and they would help me," Lynn says. Over the years she's been in group therapy, day treatment, and, when things got bad, the emergency room.

The Henry Ford approach is catching on. A stream of visitors from U.S. health insurers and from the United Kingdom have made site visits. The Suicide Prevention Resource Center has run two zero suicide training academies for teams from health care systems based on the Henry Ford principles. Other health systems have adapted the plan, including Group Health Cooperative in Seattle and the behavioral health provider Centerstone in Tennessee.

Espiritu started work at Henry Ford just as the program was starting, and she remembers the initial staff meetings: "There was a lot of, 'How can you do this? How can you aim for zero? How can you expect your clinicians to be perfect and follow this protocol?' " Some people didn't think it could be done, she says, or even attempted.

Still, the health system went ahead, and the rewards were nearly immediate. Henry Ford epidemiologist Brian Ahmedani studies the numbers. In 2009, for those being actively treated for a mental health problem or substance abuse, "we had a rate of zero per hundred thousand," he says. It's crept up to 20 per 100,000 per year, but that's still 80 percent lower than it was when the program began. The rate is five per 100,000 in the organization's general population, which is well below the national average and has remained steady despite an increasing rate of suicide statewide.

There's reason to think a full-bore effort to treat depression could reduce health costs, because untreated depression is associated with higher medical bills for chronic illnesses such as diabetes and hypertension. But there are training costs involved, and the Henry Ford system has had to keep its staffing up to be able to provide care for people who need it.

Officials at Henry Ford say they haven't analyzed the costs. But Centerstone has. The behavioral health provider in Nashville implemented the Henry Ford approach for nearly 200 patients who'd already made a suicide attempt. Reductions in emergency room visits and hospitalizations over the course of a year resulted in savings of more than $400,000.

Why push for zero, rather than just a reduction? "Because if you say we're OK with five a year, one of those might be your brother or your friend," says Espiritu. "We aim for zero because it reminds all of us of what we would want for ourselves." Maybe it is not possible, she says. But it is a goal.

And as for Lynn, she doesn't consider herself cured. She says with the treatment she's received at Henry Ford, she's learned to live, even thrive, with bipolar disease. And she's alive. That, she says, makes her a big success story.

An open-minded, skeptical look at the success of “zero suicides”: Any evidence beyond the rhetoric?

  • Claims are spreading across social media that a goal of zero suicides can be achieved by radically re-organizing resources in health systems and communities. Extraordinary claims require extraordinary evidence.
  • I thoroughly searched for evidence backing claims of “zero suicides” being achieved.
  • The claims came up short, after expectations were initially raised by some statistics and a provocative graph. But any persuasiveness to these details quickly dissipated when they were scrutinized. Lesson: Abstract numbers and graphs are not necessarily quality evidence and dazzling ones can obscure a lack of evidence.
  • The goal of “zero suicides” has attracted support of Pharma and generated programs around the world, with little fidelity to the original concept developed in the Henry Ford Health System in Detroit. In many contexts in which it is now being invoked, “zero suicides” is a vacuous buzz term, not a coherent, organizational strategy
  • Preventing suicide is a noble goal to which a lot of emotion gets attached. It also creates lucrative financial opportunities and attracts vested interests which often simply repackage existing programs for resale.
  • How can anyone oppose the idea that we should eliminate suicide? Clever sloganeering can stifle criticism and suppress embarrassing evidence to the contrary
  • Yet, we should not be bullied, nor distracted by slogans from our usual, skeptical insistence on those who make strong claims having the burden to provide strong evidence.
  • Deaths by suicide are statistically infrequent, poorly predicted events that occur in troubled contexts of interpersonal and institutional breakdown. These aspects can frustrate efforts to eliminate suicide entirely – or even accurately track these deaths.
  • Eliminating deaths by suicide is only very loosely analogous to wiping out polio and lots of pitfalls await those who get confused by a false equivalence.
  • Pursuit of the goal of “zero suicides,” particularly in under-resourced and not well-organized community settings can have unintended, negative consequences.
  • “Zero suicides” is likely a fad, to be replaced by next year’s fashion or maybe a few years after.
  • We need to step back and learn from the rise and fall of slogans and the unintended impact on distribution of scarce resources and the costs to human well-being.
  • My take away message is that increasingly sophisticated and even coercive communications about clinical and public health policies often harness the branding of prestigious medical journals. Interpreting these claims require a matching skepticism, critical thinking skills, and renewed demands for evidence.

Beginning the search for evidence for the slogan “Zero Sucide.”

Numerous gushy tweets about achieving “zero suicides” drew me into a search for more information. I easily traced the origins of the campaign to a program at the Henry Ford Health System, a Detroit-based HMO, but the concept has now gone thoroughly international. My first Google Scholar search did not yield quality evidence from any program evaluations, but a subsequent Google search produced exceptionally laudatory and often self-congratulatory statements.

I briefly diverted my efforts to contacting authorities whom I expected might comment about “zero suicides.” Some indicated a lack of familiarity prevented them from commenting, but others were as evasive as establishment Republicans asked about Donald Trump. One expert, however, was forthcoming with an interesting article, which proved to have just right tone. I recommend:

Kutcher S, Wei Y, Behzadi P. School-and Community-Based Youth Suicide Prevention Interventions Hot Idea, Hot Air, or Sham?. The Canadian Journal of Psychiatry. 2016 Jul 12:0706743716659245.

Continuing my search, I found numerous links to other articles, including a laudatory, Medical News and Perspectives opinion piece in JAMA behind a readily circumvented pay wall. There was also a more accessible source with a branding by New England Journal of Medicine.

Clicking on these links, I found editorial and even blatantly promotional material, not randomized trials or other quality evidence.

This kind of non-evidence-based publicity in highly visible medical journals is extraordinary in itself, although not unprecedented. Increasingly, the brand of particular medical journals is sold and harnessed to bestow special credibility on political and financial interests, has seen in 1 and 2.

NEJM Catalyst: How We Dramatically Reduced Suicide.

NEJM Catalyst is described as bringing

Health care executives, clinician leaders, and clinicians together to share innovative ideas and practical applications for enhancing the value of health care delivery.

The claim of “zero suicides” originated in the Perfect Care for Depression in a division of the Henry Ford Health System.

The audacious goal of zero suicides was part of the Behavioral Health Services division’s larger goal to develop a system of perfect care for depression. Our roadmap for transformation was the Quality Chasm report, which defined six dimensions of perfect care: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. We set perfection goals and metrics for each dimension, with zero suicides being the perfection goal for effectiveness. Very quickly, however, our team seized on zero suicides as the overarching goal for our entire transformation.

The strategies:

We used three key strategies to achieve this goal. The first two — improving access to care and restricting access to lethal means of suicide — are evidence-based interventions to reduce suicide risk. While we had pursued these strategies in the past, setting the target at zero suicides injected our team with gumption. To improve access to care, we developed, implemented, and tested new models of care, such as drop-in group visits, same-day evaluations by a psychiatrist, and department-wide certification in cognitive behavior therapy. This work, once messy and arduous for the PDC team, became creative, fun, and focused. To reduce access to lethal means of suicide, we partnered with patients and families to develop new protocols for weapons removal. We also redesigned the structure and content of patient encounters to reflect the assumption that every patient with a mental illness, even if that illness is in remission, is at increased risk of suicide. Therefore, we eliminated suicide screens and risk stratification tools that yielded non-actionable results, freeing up valuable time. Eventually, each of these approaches was incorporated into the electronic health record as decision support.

The third strategy:

…The pursuit of perfection was not possible without a just culture for our internal team. Ultimately, we found this the most important strategy in achieving zero suicides. Since our goal was to achieve radical transformation, not just to tweak the margins, PDC staff couldn’t justly be punished if they came up short on these lofty goals. We adopted a root cause analysis process that treated suicide events equally as tragedies and learning opportunities.

Process of patient care described in JAMA

What happens to a patient being treated in the context of Perfect Depression Care is described in the JAMA piece:

Each patient seen through the BHS is first assessed and stratified on the basis of suicide risk: acute, moderate, or low. “Everyone is at risk. It’s just a matter of whether it’s acute or whether it requires attention but isn’t emergent,” said Coffey. A patient considered to be at high risk undergoes a psychiatric evaluation the same day. A patient at low risk is evaluated within 7 days. Group sessions for patients also allow individuals to connect and offer support to one another, not unlike the supportive relationships between sponsors and “sponsees” in 12-step programs

The claim of Zero Suicides, in numbers and a graph

…A dramatic and statistically significant 80% reduction in suicide that has been maintained for over a decade, including one year (2009) when we actually achieved the perfection goal of zero suicides (see the figure below). During the PDC initiative, the annual HMO network membership ranged from 182,183 to 293,228, of which approximately 60% received care through Behavioral Health Services. From 1999 to 2010, there were 160 suicides among HMO members. In 1999, as we launched PDC, the mean annual suicide rate for these mental health patients was 110.3 per 100,000. During the 11 years of the initiative, the mean annual suicide rate dropped to 36.21 per 100,000. This decrease is statistically significant and, moreover, took place while the suicide rate actually increased among non–mental health patients and among the general population of the state of Michigan.


It is clear that rates of suicide fluctuate greatly from year-to-year in the health system. It also appears from the graph that for most years during the program, rates of suicide among patients in the Henry Ford Health System were substantially greater than those of the general population in Michigan, which were relatively flat. Any comparisons between the program and the general statistics for the state of Michigan are not particularly informative. Michigan is a state of enormous health care disparities. During this period, there was a large insured population. Demographics differ greatly, but patients receiving care within an HMO were a substantially more privileged group than the general population of Michigan. During this time, there were many uninsured and a lot of annual movement in and out of the Henry Ford Health System. At any one time, only 60% of the patients within the health system were enrolled in the behavioral health system in which the depression program occurred.

A substantial proportion of suicides occur with individuals who are not previously known to health systems. Such persons are more represented in the statistics for the state of Michigan. Another substantial proportion of suicides occur in individuals with weakened or recently broken contact with health systems. We don’t know how the statistics reported for the health system accommodated biased departures from the health system or simply missing data. We don’t know whether behavior related to risk of suicide affected migration into the health care system or to the small group receiving behavioral healthcare through the health system. For instance, what became of patients with a psychiatric disorder in a comorbid substance use disorder? Those who were incarcerated?

Basically, the success of the program is not obvious within the noisy fluctuation of suicides within the Henry Ford Health System or the smaller behavioral health program. We cannot control for basic confounding factors or selective enrollment and disenrollment in the health care system, or even expelling from the behavioral health system of persons at risk.

“Zero suicides” as a literal and serious goal?

The NEJM Catalyst article gave the originator of the program free reign for self-praise.

The most unexpected hurdles were skepticism that perfection goals like zero suicides were reasonable or feasible (some objected that it was “setting us up for failure”), and disbelief in the dramatic improvements obtained (we heard comments like “results from quality improvement projects aren’t scientifically rigorous”). We addressed these concerns by ensuring the transparency of our results and lessons, by collaborating with others to continually improve our methodological issues, and by supporting teams across the world who wish to pursue similar initiatives.

Our team challenged this assumption and asked, If zero is not the right goal for suicide occurrence, then what number is? Two? Twelve? Which twelve? In spite of its radicalism — indeed because of it — the goal of zero suicides became the galvanizing force behind an effort that achieved one of the most dramatic and sustained reductions in suicide in the clinical literature.

Will the Henry Ford program prove sustainable?

Edward Coffey moved to President, CEO, and Chief of Staff at the Menninger Clinic 18 months before his article in the NEJM Catalyst. I am curious to what aspects of his Zero Suicides/Perfect Depression Care Program are still maintained at Henry Ford. As it is described, the program was designed with admirably short waiting times for referral to behavioral healthcare. If the program persists as originally described, many professionals are kept vigilant and engaged in activities to reduce suicide without any statistical likelihood of having the opportunity to actually prevent one.

In decades of work within health systems, I have found that once demonstration projects have run their initial course, their goals are replaced by new organizational ones and resources are redistributed. Sooner or later, competing demands for scarce resources are promoted by new slogans.

What if Perfect Depression Care has to compete for scarce resources with Perfect Diabetes Care or alleviation of gross ethnic disparities in cardiovascular outcomes?

A lot of well-meant slogans ultimately have unintended, negative consequences. “Make pain the 5th vital sign” led to more attention being paid to previously ignored and poorly managed pain. This was followed by mandated routine assessment and intervention, which led to unnecessary procedures and unprecedented epidemic of addiction and death from prescribed opioids. “Stamp out distress” has led to mandated screening and intervention programs for psychological distress in cancer care, with high rates of antidepressant prescription without proper diagnosis or follow-up.

If taken literally and seriously, a lofty, but abstract goal like Zero Suicide becomes a threat to any “just culture” in healthcare organization. If the slogan is taken seriously as resources are inevitably withdrawn, a culture of blame will emerge and pressures to distort easily manipulated statistics. Patients posing threats to the goal of zero suicide will be excluded from the system with an unknown, but negative consequences for their morbidity and mortality.

Bottom line – we can’t have slogan-driven healthcare policies that will likely have negative implications and conflict with evidence.

Enter Big Pharma

Not unexpectedly, Big Pharma is getting involved in promoting Zero Suicides:

Eli Lilly and Company Foundation donates $250,000 to expand Community Health Network’s Zero Suicides prevention initiative,

Major gift will save Hoosier lives through a suicide prevention network that responds to a critical Indiana healthcare issue.

According to press coverage, the funds will go to:

The Lilly Foundation donation also provides resources needed to build a Central Indiana crisis network that will include Indiana’s schools, foster care system, juvenile justice program, primary and specialty healthcare providers, policy makers and suicide survivors. These partners will be trained to identify people at risk of attempting suicide, provide timely intervention and quickly connect them with Community’s crisis providers. Indiana’s state government is a key partner in building the statewide crisis network.

I’m sure this effort is good for the profits of Pharma. Dissemination of screening programs into settings that are not directly connected to quality depression care is inevitably ineffective. The main healthcare consequences are an increase in antidepressant prescriptions without appropriate diagnoses, patient education, and follow-up. Substantial overtreatment results from people being identified without proper diagnosis who otherwise would not be seeking treatment. Care for depression in the community is hardly Perfect Depression Care.

It is great publicity for Eli Lilly and the community receiving the gift will surely be grateful.

Launching Zero Suicides in English communities and elsewhere

My academic colleagues in the UK assure me that we can simply dismiss an official UK government press release about the goal of zero suicides from Nick Clegg. It has been rendered obsolete by subsequent political events. A number commented that they never took it seriously, regardless.

The claims in the press release stand in stark contrast to long waiting times for mental health services and important gaps in responses to serious mental health crises, including lethal suicide attempts. However, another web link is to an announcement:

Centre for Mental Health was commissioned by the East of England Strategic Clinical Networks to evaluate activity taking place in four local areas in the region through a pilot programme to extend suicide prevention into communities.

The ‘zero suicide’ initiative is based on an approach developed by Dr Ed Coffey in Detroit, Michigan. The approach aims to prevent suicides by creating a more open environment for people to talk about suicidal thoughts and enabling others to help them. It particularly aims to reach people who have not been reached through previous initiatives and to address gaps in existing provision.

Four local areas in the East of England (Bedfordshire, Cambridgeshire & Peterborough, Essex and Hertfordshire) were selected in 2013 as pathfinder sites to develop new approaches to suicide prevention. Centre for Mental Health evaluated the work of the sites during 2015.

The evaluation found an impressive range of activities that had taken suicide prevention activities out into local communities. They included:

  • Training key public service staff such as GPs, police officers, teachers and housing officers
  • Training others who may encounter someone at risk of taking their own life, such as pub landlords, coroners, private security staff, faith groups and gym workers
  • Creating ‘community champions’ to put local people in control of activities
  • Putting in place practical suicide prevention measures in ‘hot spots’ such as bridges and railways
  • Working with local newspapers, radio and social media to raise awareness in the wider community
  • Supporting safety planning for people at risk of suicide, involving families and carers throughout the process
  • Linking with local crisis services to ensure people get speedy access to evidence-based treatments

    The report noted that some of the people who received the training had already saved lives:

    “I saved a man’s life using the skills you taught us on the course. I cannot find words to properly express the gratitude I have for that. Without the training I would have been in bits. It was a very public place, packed with people – but, to onlookers, we just looked like two blokes sitting on a bench talking.”

“Déjà vu all over again”, as Yogi Berra would say. This effort also recalls Bill Murray in the movie Groundhog Day, where he is trapped into repeating the same day over and over again.

A few years ago I was a scientific advisor for European Union funded project to disseminate multilevel suicide prevention programs across Europe. One UK site was among those targeted in this report. Implementation of the EU program had already failed before the plate of snacks was being removed from a poorly attended event. The effort quickly failed because it failed to attract the support of local GPs.

Years later, I recognize many of the elements of what we tried to implement, described in language almost identical to ours. There is no mention of the training materials we left behind or of the quick failure of our attempt at implementation.

Many of the proposed measures in the UK plan serve to generate publicity and do not any evidence that they reduce suicides. For instance, training people in the community who might conceivably come in contact with a suicidal person accomplishes little other than producing good publicity. Uptake of such training is abysmally low and is not likely to affect the probability that a person in a suicidal crisis will encounter anyone who can make a difference

Broad efforts to increase uptake of mental health services in the UK strain a system already suffer from unacceptably long waiting times for services. People with any likelihood of attempting suicide, however poorly predicted, are likely to be lost among persons seeking services with less serious or pressing needs.

Thoughts I have accumulated from years of evaluating depression screening programs and suicide intervention efforts

Staying mobilized around preventing suicide is difficult because it is an infrequent event and most activations of resources will prove to false positives.

It can be tedious and annoying for both staff and patients to keep focused on an infrequent event, particularly for the vast majority of patients who rightfully believe they are not at risk for suicide.

Resources can be drained off from less frequent, but more high risk situations that require sustained intensity of response, pragmatic innovation, and flexibility of rules.

Heightened efforts to detect mental health problems increase access for people already successfully accessing services and decrease resources for those needing special efforts. The net result can be an increase in disparities.

Suicide data are easily manipulated by ignoring selective loss to follow-up. Many suicides occur at breaks in the system, where getting follow-up data is also problematic.

Finally, death by suicide is a health outcomes that is multiply determined. It does not lend itself to targeted public health approaches like eliminating polio, tempting though invoking the analogy may be.


It is likely that I exposed anyone reaching this postscript to a new and disconcerting perspective. What I have been saying is discrepant with the publicity about “zero suicides” available in the media. The portrayal of “zero suicides” is quite persuasive because it is sophisticated and well-crafted. Its dissemination is well resourced and often financed by individuals and institutions with barely discernible – if at all – conflicts of financial and political interests. Just try to find any dissenters or skeptical assessments.

My takeaway message: It’s best to process claims about suicide prevention with a high level of skepticism, an insistent demand for evidence, and a preparedness for discovering that seemingly well trusted sources are not without agendas. They are usually providing propaganda rather than evidence-based arguments.

Attempters’ Longterm Survival

Nine out of ten people who attempt suicide and survive will not go on to die by suicide at a later date. This has been well-established in the suicidology literature. A literature review (Owens 2002) summarized 90 studies that have followed over time people who have made suicide attempts that resulted in medical care. Approximately 7% (range: 5-11%) of attempters eventually died by suicide, approximately 23% reattempted nonfatally, and 70% had no further attempts.

Even studies that focused on medically serious attempts–such as people who jumped in front of a train (O’Donnell 1994)–and studies that followed attempters for many decades found similarly low suicide completion rates. At least one study, published after the 90-study review, found a slightly higher completion rate. This was a 37-year follow-up of self-poisoners in Finland that found an eventual completion rate of 13% (Suominen 2004).

This relatively good long-term survival rate is consistent with the observation that suicidal crises are often short-lived, even if there may be underylying, more chronic risk factors present that give rise to these crises.

The relationship between suicide attempts and completions is a complex one.

Most people who die by suicide in the U.S. did not make a previous attempt. Prevention efforts that focus only on those who attempt suicide will miss the majority of completers. An international review of psychological autopsy studies found that approximately 40% of those dying by suicide had previously attempted (Cavanagh 2003). The proportion was lower (25-33%) among studies of youth suicide in the U.S. (Brent 1993, Shaffer 1996). A history of previous attempts is lower among those dying by firearm suicide and higher among those dying by overdose (NVISS data).

Most people who attempt suicide will not go on to complete suicide.

Still, history of suicide attempt is one of the strongest risk factors for suicide. 5% to 11% of hospital-treated attempters do go on to complete suicide, a far higher proportion than among the general public where annual suicide rates are about 1 in 10,000.

Suicide statistics

The first thing you should be aware of if you are trying to kill yourself is, the odds are against you. Yes, I'll say that again - the odds are against you. According to the American Association of Suicidology (based on a SAMHSA study)1, there are 25 attempts at suicide for every one success.

In young people (aged 15 - 24), the odds are between 100 and 200 to 1 against. The elderly seem a lot more successful at 4:1.

Women are three times more likely to make an unsuccessful attempt than a man, yet will attempt suicide two to three times more often. However, this does depend on their age, as younger women make many more attempts than men, whereas women older than 50 make slightly less attempts than men 2.

According to the 2008 National Survey on Drug Use and Health 3, in the US there were 8.3m adults who had serious thoughts of committing suicide, and 2.3m who had actually made plans to commit to suicide. Of those, 1.1m actually attempted suicide, but only just over 33,000 succeeded. Which would make the ratio of failure to success 33 to 1.

In 2011, it was estimated by SAMHSA4 that attempted suicide led to 228,366 emergency department (ED) visits. Almost all involved a prescription drug or over-the-counter medication. It is worth noting that with only 5,465 actually succeeding in suicide using drugs, it means there were 42 ED visits for every successful suicide. Sobering odds of success, and there are probably lots of attempts that don’t even end up in hospital.

Suicide statistics

According the World Health Organisation5, in the year 2000, there were approximately 1m suicides globally. However, another study6 for the WHO states that the suicide figures from some countries may be underreported by between 20% and 100%, so the death toll could well be higher. Worldwide, suicide rates have increased by 60% over the last 50 years, and the increase has been particularly marked in developing countries.

The WHO estimates that globally there are at least 20 suicide attempts for every success, meaning that there are least 20m, yes, 20million, attempted suicides every year - and rising.

In a study done in Oxford UK7, 864 people who attempted suicide (and survived) were asked to rate, on a scale of 1 to 30, how intent they were on killing themselves (where 30 was totally intent, and 1 was hardly at all). The results are below:

Rating of suicidal intent
% of respondents

Low (0-6)


Moderate (7-12)


High (13-20


Very High (21+)


The message here is that two thirds of people that try to kill themselves are not that intent on succeeding. Maybe there's a part of them that wanted to end it, and a part didn't, and due to some event that tipped them over the edge, they tried to commit suicide.

So what are the messages here? Firstly, you are not alone. Suicide is a major problem. We are living in a society where more and more people are considering suicide. Second, note that anyone thinking of trying to kill themselves is much more likely to screw it up than succeeding. The odds globally are at least 20 to 1 against, and in the US quite possibly 33 to 1 against or higher. And many of those unsuccessful attempts end up with people having nasty short or long term health implications. And third, many people who actually try and commit suicide say after the event they weren't that intent on doing it. Many people attempt suicide on impulse, and then end up living with serious health implications.

So anyone thinking of suicide should first read Help me It is not the only option. If you are still intent on attempting to take your own life, be sure to read the dangers of whatever method you are considering, and think it over again. The pain you are currently going through might be nothing compared to pain you are about to put yourself through trying to kill yourself.


USA Suicide 2012 Official Final Data: CW Drapeau & JL McIntosh for the American Association of Suicidology October 2014 (from

The changing gender ratio in occurrence of deliberate self-harm across the life-cycle. Hawton, K, Harriss, L (2008) Crisis, 29, 4-10.

Substance Abuse and Mental Health Services Administration (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD. and

Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies. Drug Abuse Warning Network (DAWN): National estimates of drug-related emergency department visits for 2011, Table 22 (

World Health Organisation, Preventing suicide - A global imperative, 2014:

JM Bertolote and A Fleischmann (October 2002), Suicide and psychiatric diagnosis: a worldwide perspective. Mental health Policy Paper for the Department of Mental Health and Substance Dependence, World Health Organization. Published in World Psychiatry 1 (3): 181-5. ISSN 1723-8617.

K Hawton, D Casey, E Bale, A Shepherd, H Bergen and S Simkin, Deliberate Self-Harm in Oxford 2007. University of Oxford Centre for Suicide Research (from


Suicide: Statistics, Warning Signs and Prevention

Every year, tens of thousands of Americans die from suicide. It is the third leading cause of death among young people between the ages of 10 and 24, amounting to about 4,600 deaths a year. Suicide is also the 10th leading cause of death of Americans older than age 10, killing more people than car crashes or any other cause of injury, according to the U.S. Centers for Disease Control and Prevention (CDC).

"For reasons we don't fully understand, some people reach such depths of despair and pain that they begin to believe that they would be better off dead," said Dr. John Campo, the chair of psychiatry and behavioral health at The Ohio State University Wexner Medical Center.

Though suicide often seems mysterious and unpreventable, it can be stopped, experts say. Talking openly about people's suicidal thoughts and keeping them away from lethal means (such as firearms) can save lives.

For immediate help, call the National Suicide Prevention Lifeline at 800-273-8255 or text the Crisis Text Line at 741741

Improving diagnosis of mental health conditions can help, too. Most people who commit suicide have seen a doctor within the last year, but many do not get diagnosed with the mental illness that will ultimately kill them. [5 Myths About Suicide, Debunked]

Suicide rates and statistics

In 2010, the most recent year comprehensive data is available from the CDC, there were 38,364 suicides in the United States. Meanwhile, suicidal thoughts and plans are even more widespread: 8.3 million American adults reported having suicidal thoughts in the past year, 2.2 million went as far as to make plans, and 1 million made a suicide attempt. (In 2013, about 41,100 people committed suicide in the United States, according to the CDC).

Men are four times more likely than women to kill themselves, and 79 percent of U.S. suicides are completed by men, the CDC said. This disparity is partially due to men choosing more lethal means to kill themselves: 56 percent die by firearm. Women are more likely to attempt suicide by self-poisoning.

"Women more likely to attempt suicide, and men more likely to complete [it]," Campo said.

There are racial disparities in suicide, as well. American Indians, Alaskan Natives and white men are at the highest risk. Asian/Pacific Islanders have the lowest suicide rate for men, and African Americans have the lowest rate for women, according to the CDC.

Suicide surpassed car crashes as the No. 1 cause of injury-related death in 2012, researchers reported in November 2012 in the American Journal of Public Health. Between 2000 and 2009, the suicide rate went up 15 percent, researchers found. The number of deaths from car wrecks dropped 25 percent in that same time period.

An increase in suicides among middle-age Americans from 2005 to 2010 may be in response to the economic recession of 2007, a 2015 study in the American Journal of Preventive Medicine found. Also, adolescents and young adults in rural areas are more likely to commit suicide than those in urban regions, a 2015 study in the journal JAMA Pediatrics found.

For reasons not fully understood, suicides are more common in spring. This springtime peak may be the result of a loss of hope as the weather warms but life doesn't seem to improve for the depressed person. Alternatively, increased sociality during warmer months could put extra pressure on someone who is struggling. Some scientists even believe that inflammation from spring allergens could exacerbate mental illness, though those connections are unproven.

Suicide warning signs

The biggest risk factor for committing suicide is having previously attempted to kill oneself. The vast majority of people who do kill themselves have a mental illness. More than 90 percent of people who kill themselves have a mental disorder, whether depression, bipolar disorder or some other diagnosis, according to the National Alliance on Mental Illness (NAMI). [Suicide: Red Flags and Warning Signs]

Substance abuse is another risk factor, in part because drugs and alcohol lower inhibitions, making it easier for people to act on their suicidal thoughts. One-third of people who killed themselves in 2009 had alcohol in their systems, according to the CDC. About a fifth (20.8 percent) tested positive for opiates, which include prescription pain medications and heroin.

People with a family history of suicide, childhood trauma or who have impulsive aggression are more likely to commit suicide themselves, Campo said. For people with an underlying mental illness, stressful situations (such as bullying, relationship conflict or unemployment) can increase risk. Suicide can also be contagious, which is why suicide prevention groups advise that media reports about suicide avoid sensationalism or descriptions of the act.

Immediate warning signs that someone may be in a suicidal crisis include:

  • feelings of hopelessness or desperation
  • insomnia
  • panic attacks
  • social isolation
  • irritability
  • rage
  • feelings of being a burden

Suicide prevention

Between 50 percent and 75 percent of people who attempt suicide talk about their suicidal thoughts, feelings and plans before the act, according to the American Foundation for Suicide Prevention (AFSP).

Many suicidal people struggle intensely with ambivalence, and it's important to guide them toward help, Campo said.

"They want to live, they want to die," Campo said. "People are in a quandary. They're in terrible pain. The important thing for suicidal people to understand is that it passes."

If someone you know is acting suicidal, the AFSP recommends talking with them immediately and openly. Many people view suicide as a taboo subject, and Campo told Live Science that he often has to ask his patients repeatedly about suicide before they admit to thinking about or planning their death.

Asking about suicidal thoughts does not put those thoughts into people's heads, so finding out if they have a specific plan is important. Let the person know you are concerned and focus on getting them proper mental health treatment.

"Your goal isn't so much to really talk them out of it," Campo said. "Your goal is to help engage them and get them involved with some help so that they can get the treatment that they need."

Do not leave a suicidal person alone, and remove drugs, sharp objects and firearms. Access to lethal means during a suicidal crisis is a major risk factor for suicide. Call the National Suicide Prevention Lifeline at 800-273-8255 or text the Crisis Text Line 741741 or get the person to a psychiatric clinic or emergency room for help.

Additional reporting by Live Science Staff Writer Laura Geggel. Follow her on Twitter @LauraGeggel. Follow Live Science @livescience, Facebook & Google+.

Additional resources

Learn ways to prevent suicide at the American Foundation for Suicide Prevention.

Therapy can reduce repeat suicide attempts, according to an article in The New York Times.


Suicide Facts

Did You Know?...

  • Over 48,000 people in the U.S. kill themselves every year.
  • Suicide is the third leading cause of death for 15 – 24 year olds.
  • 1 out of 5 high school students will consider suicide.
  • Suicide is the second leading cause of death for college age teens.
  • 1 out of 12 college students has a suicide plan.
  • More children and young adults die from suicide every year than from cancer, heart disease, AIDS, birth defects, stroke and chronic lung disease combined.
  • Every suicide intimately affects 6 other people.
  • Suicide has increased 100% in the past two years for ages 10 – 14 year olds.
  • For every completed suicide by youth it is estimated that 100 – 200 attempts are made.
  • Males are four times more likely to die from suicide than females.
  • Females attempt suicide four times more than males.
  • In 2003 one out of sixty-five Americans lost someone to suicide.
  • In the U.S. 100 teens a week die from suicide.
  • More people die from suicide than from homicide.
  • 1 out of 4 people diagnosed with bi-polar disorder will attempts suicide.


Youth Suicide Statistics

  • Suicide is the SECOND leading cause of death for ages 10-24. (2014 CDC WISQARS)
  • Suicide is the SECOND leading cause of death for college-age youth and ages 12-18. (2014 CDC WISQARS)
  • More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease, COMBINED.
  • Each day in our nation, there are an average of over 5,240 attempts by young people grades 7-12.
  • Four out of Five teens who attempt suicide have given clear warning signs

The Youth Risk Behavioral Surveillance System (YRBS) is a survey, conducted by the Centers for Disease Control and Prevention, that includes national, state, and local school-based representative samples of 9th through 12th grade students. The purpose is to monitor priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth in the United States.

The surveys are conducted every two years to determine the prevalence of these health risk behaviors. Behaviors that contribute to unhealthy lifestyles and those that indicate possible depression and/or suicidal ideation are included. Click here for the full report

No suicide attempt should be dismissed or treated lightly!

Why Do People Attempt Suicide?

A suicide attempt is a clear indication that something is gravely wrong in a person’s life. No matter the race or age of the person; how rich or poor they are, it is true that most people who die by suicide have a mental or emotional disorder. The most common underlying disorder is depression, 30% to 70% of suicide victims suffer from major depression or bipolar (manic-depressive) disorder.

Warning Signs of Someone Considering Suicide

Any one of these signs does not necessarily mean the person is considering suicide, but several of these symptoms may signal a need for help:

  • Verbal suicide threats such as, “You’d be better off without me.” or “Maybe I won’t be around”
  • Expressions of hopelessness and helplessness
  • Previous suicide attempts
  • Daring or risk-taking behavior
  • Personality changes
  • Depression
  • Giving away prized possessions
  • Lack of interest in future plans

Remember: Eight out of ten people considering suicide give some sign of their intentions. People who talk about suicide, threaten suicide, or call suicide crisis centers are 30 times more likely than average to kill themselves.

If You Think Someone Is Considering Suicide

  • Trust your instincts that the person may be in trouble
  • Talk with the person about your concerns. Communication needs to include LISTENING
  • Ask direct questions without being judgmental. Determine if the person has a specific plan to carry out the suicide. The more detailed the plan, the greater the risk
  • Get professional help, even if the person resists
  • Do not leave the person alone
  • Do not swear to secrecy
  • Do not act shocked or judgmental
  • Do not counsel the person yourself

Suicide Statistics

  • Suicide is the eighth leading cause of death in the United States, accounting for more than 1% of all deaths
  • More years of life are lost to suicide than to any other single cause except heart disease and cancer
  • 30,000 Americans die by suicide each year; an additional 500,000 Americans attempt suicide annually
  • The actual ratio of attempts to completed suicides is probably at least 10 to 1
  • 30% to 40% of persons who complete suicide have made a previous attempt
  • The risk of completed suicide is more than 100 times greater than average in the first year after an attempt - 80 times greater for women, 200 times greater for men, 200 times greater for people over 45, and 300 times greater for white men over 65
  • Suicide rates are highest in old age: 20% of the population and 40% of suicide victims are over 60. After age 75, the rate is three times higher than average, and among white men over 80, it is six times higher than average
  • Substance abuse is another great instigator of suicide; it may be involved in half of all cases. About 20% of suicides involve people with alcohol problems, and the lifetime rate of suicide among people with alcohol-use problems is at least three or four times the average. Completed suicides are more likely to be men over 45 who are depressed or alcoholic.

Preventing Suicide

Although they may not call prevention centers, people considering suicide usually do seek help; for example, 64% of people who attempt suicide visit a doctor in the month before their attempt, and 38% in the week before.1

Helping Someone Who is Considering Suicide

No single therapeutic approach is suitable for all people considering suicide or suicidal tendencies. The most common ways to treat underlying illnesses associated with suicide are with medication, talk therapy or a combination of the two.

Cognitive (talk therapy) and behavioral (changing behavior) therapies aim at relieving the despair of suicidal patients by showing them other solutions to their problems and new ways to think about themselves and their world. Behavioral methods, such as training in assertiveness, problem-solving, social skills, and muscle relaxation, may reduce depression, anxiety, and social ineptitude.

Cognitive and behavioral homework assignments are planned in collaboration with the patient and explained as experiments that will be educational even if they fail. The therapist emphasizes that the patient is doing most of the work, because it is especially important for a person thinking about suicide not to see the therapist as necessary for their survival.

Recent research strongly supports the use of medication to treat the underlying depression associated with suicide. Antidepressant medication acts on chemical pathways of the brain related to mood. There are many very effective antidepressants. The two most common types are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Other new types of antidepressants (e.g. alpha-2 antagonist, selective norepinephrine reuptake inhibitors (SNRIs) and aminoketones), and an older class, monoamine oxidase inhibitors (MAOIs), are also prescribed by some doctors.

Antidepressant medications are not habit-forming. Although some symptoms such as insomnia, often improve within a week or two, it may take three or four weeks before you feel better; the full benefit of medication may require six to eight weeks of treatment. Sometimes changes need to be made in dosage or medication type before improvements are noticed. It is usually recommended that medications be taken for at least four to nine months after the depressive symptoms have improved. People with chronic depression may need to stay on medication to prevent or lessen further episodes.

People taking antidepressants should be monitored by a doctor who knows about treating clinical depression to ensure the best treatment with the fewest side effects. It is also very important that your doctor be informed about all other medicines that are taken, including vitamins and herbal supplements, in order to help avoid dangerous interactions. Alcohol or other drugs can interact negatively with antidepressant medication.

Do not discontinue medication without discussing the decision with your doctor.

Resources in Your Community

Telephone hotlines (Can be obtained from the telephone book, local Mental Health Associations, community centers, or United Way chapters)

  • Clergy
  • Medical professionals
  • Law-enforcement agencies

More Information

If you or someone you know is contemplating suicide, call 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255) will connect you with a crisis center in your area.


Most youth in crisis will not call a phone line center but they will text. Have them text 741741, the Crisis Text Line. Service is 24/7, free and confidential and you will be directed to a crisis center in your district, similar to the hopeline phone system.

Other Resources

Emergency numbers

American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Ave., N.W.
Washington, D.C. 20016-3007
Phone Number: (202) 966-7300
Fax: (202) 966-2891
Email Address:
Website URL:

American Association of Suicidology
Phone Number: (202) 237-2280
Website URL:

American Foundation for Suicide Prevention
Phone Number: 888-333-AFSP (2377)
Website URL:


1 Ahmedani, Brian K. "Racial/Ethnic Differences in Health Care Visits Made Before Suicide Attempt Across the United States." Medical Care 53.5 (May 2015): 430-35. Web.

Therapy Prevents Repeat Suicide Attempts

Short-term psychotherapy may be an effective way to prevent repeated suicide attempts.

Using detailed Danish government health records, researchers studied 5,678 people who had attempted suicide and then received a program of short-term psychotherapy based on needs, including crisis intervention, cognitive therapy, behavioral therapy, and psychodynamic and psychoanalytic treatment. They compared them with 17,034 people who had attempted suicide but received standard care, including admission to a hospital, referral for treatment or discharge with no referral. They were able to match the groups in more than 30 genetic, health, behavioral and socioeconomic characteristics. The study is online in Lancet Psychiatry.

Treatment focused on suicide prevention and comprised eight to 10 weeks of individual sessions.

Over a 20-year follow-up, 16.5 percent of the treated group attempted suicide again, compared with 19.1 percent of the untreated group. In the treated group, 1.6 percent died by suicide, compared with 2.2 percent of the untreated.

“Suicide is a rare event,” said the lead author, Annette Erlangsen, an associate professor at the Johns Hopkins Bloomberg School of Public Health, “and you need a huge sample to study it. We had that, and we were able to find a significant effect.”

The authors estimate that therapy prevented 145 suicide attempts and 30 deaths by suicide in the group studied.

Suicide often not preceded by warnings

A close friend of one of my colleagues committed suicide last week. It happened as so many suicides do—out of the blue. A few days earlier, my colleague had spent the day hanging out with her friend, who was relaxed, upbeat, and normal.

Sadly, that’s not uncommon. “Many people who commit suicide do so without letting on they are thinking about it or planning it,” says Dr. Michael Miller, assistant professor of psychiatry at Harvard Medical School.

More than 100 Americans commit suicide every day. It’s the tenth leading cause of death overall; third among 15- to 24-year-olds and fourth among 25- to 44-year-olds.

Although some people who commit suicide have an identifiable mental health problem, like depression or addiction, others don’t. Some talk about wanting or planning to kill themselves or give other hints, others don’t. As my colleague Annmarie Dadoly wrote in this blog last year, many suicides are impulsive acts, with the decision to do it being made just minutes or hours before that act.

What prompts a person to take his or her life? No one really knows—experts never get to talk to people who have committed suicide. They can only talk to those who are contemplating suicide or who survive it. By definition, that is a different group.

Every suicide, like every person, is different. Many are sparked by intense feelings of anger, despair, hopelessness, or panic. Things that can put an individual at a higher risk for suicide in the short term include:

  • an episode of depression, psychosis, or anxiety
  • a significant loss, such as the death of a partner or the loss of a job
  • a personal crisis or life stress, especially one that increases a sense of isolation or leads to a loss of self-esteem, such as a breakup or divorce
  • loss of social support, for example, because of a move or when a close friend relocates
  • an illness or medication that triggers a change in mood
  • exposure to the suicidal behaviors of others, such as friends, peers, or celebrities.

We all face crises or problems like these. One difference is that among individuals who take their own lives, these situations cause such pain or hopelessness they can’t see any other way out.

No warnings

Suicide almost always raises anguished questions among family members and friends left behind: What did I miss? What could I have done? In my friend’s case, the answers are nothing and nothing.

“Many people never let on what they are feeling or planning. The paradox is that the people who are most intent on committing suicide know that they have to keep their plans to themselves if they are to carry out the act,” says Dr. Miller. “Thus, the people most in need of help may be the toughest to save.”

Some suicides (and suicide attempts), though, don’t come completely out of the blue. Some people — including those who are more ambivalent about suicide — consciously or unconsciously drop hints. Here are a few behaviors that may put friends and family on notice that the risk of suicide is on the rise (adapted from

  • Talking about suicide: Statements like “I’d be better off dead” or “If I see you again…,”
  • Seeking the means: Trying to get access to guns, pills, or other objects that could be used in a suicide attempt.
  • No hope for the future: Feelings of helplessness, hopelessness, and being trapped, or believing that things will never get better.
  • Self-loathing: Feelings of worthlessness, guilt, shame, and self-hatred.
  • Getting affairs in order: Giving away prized possessions or making arrangements for family members.
  • Saying goodbye: Unusual or unexpected visits or calls to family and friends; saying goodbye to people as if they won’t be seen again.

People who exhibit these signs are often communicating their distress, hoping to get a response. This is very useful information that shouldn’t be ignored.

If you think a loved one or friend might hurt himself or herself, call the National Suicide Prevention Lifeline at 800-273-TALK. Counselors are available 24 hours a day, 7 days a week. The service is available to anyone. All calls are confidential.

But when individuals suddenly take their own lives with no warning, all we can do is look to each other for support. It may be natural to ask, “What did I miss?” But we should remind ourselves what experts say: This kind of death defies prediction. (The American Association of Suicidology offers helpful resources for survivors of those who committed suicide.)

Teen suicide tries increased after FDA toughened
Suicide survivors face grief, questions, challenges
Why men often die earlier than women


The Six Reasons People Attempt Suicide

Though I've never lost a friend or family member to suicide, I have lost a patient (who I wrote about in a previous post, The True Cause Of Depression). I have known a number of people left behind by the suicide of people close to them, however. Given how much losing my patient affected me, I've only been able to guess at the devastation these people have experienced. Pain mixed with guilt, anger, and regret makes for a bitter drink, the taste of which I've seen take many months or even years to wash out of some mouths.

The one question everyone has asked without exception, that they ache to have answered more than any other, is simply: why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note explaining the reasons is found, lingering questions usually remain: yes, they felt enough despair to want to die, but why did they feel that? A person's suicide often takes the people it leaves behind by surprise (only accentuating survivor's guilt for failing to see it coming).

People who've survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy but a valid one nevertheless. If some in-between state existed, some other alternative to death, I suspect many suicidal people would take it. For the sake of all those reading this who might have been left behind by someone's suicide, I wanted to describe how I was trained to think about the reasons people kill themselves. They're not as intuitive as most think.

In general, people try to kill themselves for six reasons:

They're depressed. This is without question the most common reason people commit suicide. Severe depression is always accompanied by a pervasive sense of suffering as well as the belief that escape from it is hopeless. The pain of existence often becomes too much for severely depressed people to bear. The state of depression warps their thinking, allowing ideas like "Everyone would all be better off without me" to make rational sense. They shouldn't be blamed for falling prey to such distorted thoughts any more than a heart patient should be blamed for experiencing chest pain: it's simply the nature of their disease. Because depression, as we all know, is almost always treatable, we should all seek to recognize its presence in our close friends and loved ones. Often people suffer with it silently, planning suicide without anyone ever knowing. Despite making both parties uncomfortable, inquiring directly about suicidal thoughts in my experience almost always yields an honest response. If you suspect someone might be depressed, don't allow your tendency to deny the possibility of suicidal ideation prevent you from asking about it.

They're psychotic. Malevolent inner voices often command self-destruction for unintelligible reasons. Psychosis is much harder to mask than depression, and is arguably even more tragic. The worldwide incidence of schizophrenia is 1% and often strikes otherwise healthy, high-performing individuals, whose lives, though manageable with medication, never fulfill their original promise. Schizophrenics are just as likely to talk freely about the voices commanding them to kill themselves as not, and also, in my experience, give honest answers about thoughts of suicide when asked directly. Psychosis, too, is treatable, and usually must be treated for a schizophrenic to be able to function at all. Untreated or poorly treated psychosis almost always requires hospital admission to a locked ward until the voices lose their commanding power.

They're impulsive. Often related to drugs and alcohol, some people become maudlin and impulsively attempt to end their own lives. Once sobered and calmed, these people usually feel emphatically ashamed. The remorse is often genuine, but whether or not they'll ever attempt suicide again is unpredictable. They may try it again the very next time they become drunk or high, or never again in their lifetime. Hospital admission is therefore not usually indicated. Substance abuse and the underlying reasons for it are generally a greater concern in these people and should be addressed as aggressively as possible.

They're crying out for help, and don't know how else to get it. These people don't usually want to die but do want to alert those around them that something is seriously wrong. They often don't believe they will die, frequently choosing methods they don't think can kill them in order to strike out at someone who's hurt them, but they are sometimes tragically misinformed. The prototypical example of this is a young teenage girl suffering genuine angst because of a relationship, either with a friend, boyfriend, or parent, who swallows a bottle of Tylenol, not realizing that in high enough doses Tylenol causes irreversible liver damage. I've watched more than one teenager die a horrible death in an ICU days after such an ingestion when remorse has already cured them of their desire to die and their true goal of alerting those close to them of their distress has been achieved.

They have a philosophical desire to die. The decision to commit suicide for some is based on a reasoned decision, often motivated by the presence of a painful terminal illness from which little to no hope of reprieve exists. These people aren't depressed, psychotic, maudlin, or crying out for help. They're trying to take control of their destiny and alleviate their own suffering, which usually can only be done in death. They often look at their choice to commit suicide as a way to shorten a dying that will happen regardless. In my personal view, if such people are evaluated by a qualified professional who can reliably exclude the other possibilities for why suicide is desired, these people should be allowed to die at their own hands.

They've made a mistake. This is a recent, tragic phenomenon in which typically young people flirt with oxygen deprivation for the high it brings and simply go too far. The only defense against this, it seems to me, is education.

The wounds suicide leaves in the lives of those left behind by it are often deep and long lasting. The apparent senselessness of suicide often fuels the most significant pain. Thinking we all deal better with tragedy when we understand its underpinnings, I've offered the preceding paragraphs in hopes that anyone reading this who's been left behind by a suicide might be able to more easily find a way to move on, to relinquish their guilt and anger, and find closure. Despite the abrupt way you may have been left, guilt and anger don't have to be the only two emotions you're doomed to feel about the one who left you.


If someone is seriously contemplating suicide, do you really think it is possible for them to make a decision to live?

We know that those at risk for suicide do not necessarily want to die, but do want help in reducing the pain they are experiencing so that they can go on to lead productive, fulfilling lives. There is a lot of ambivalence surrounding the decision to take one’s own life, and by recognizing this, and discussing it, we can help the suicidal person start to recognize alternative options for managing their suffering. Often suicidal people are experiencing intolerable emotional pain, which they believe to be unrelenting. They often feel hopeless and trapped. By helping them to recognize and explore alternatives to dying, you are planting the seeds of hope that things can improve.

Will talking about suicide to a person make them suicidal?

There is no research evidence that indicates talking to people about suicide, in the context of care, respect, and prevention, increases their risk of suicidal ideation or suicidal behaviours. Research does indicate that talking openly and responsibly about suicide lets a potentially suicidal person know they do not have to be alone, that there are people who want to listen and who want to help. Most people are relieved to finally be able to talk honestly about their feelings, and this alone can reduce the risk of an attempt.

Is talking about suicide, or threatening to kill yourself just a ploy to get attention?

It is best to treat talk and threats about suicide seriously. Research indicates that up to 80% of suicidal people signal their intentions to others, in the hope that the signal will be recognized as a cry for help. These signals often include making a joke or threat about suicide, or making a reference to being dead. If we do take them seriously and ask them if they mean what they are saying, the worst that can happen is we will learn that they really were joking. Not asking could result in a far worse outcome.

If someone makes a suicide attempt, but does not die, is this just looking for attention?

At some level, all suicide attempts are cries for help by individuals experiencing a high degree of desperation. It is important to treat all attempts as serious. Once an attempt is made at any level of lethality, the risk for future and more serious attempts and completion increases significantly.

If a person who was depressed and suicidal suddenly seems to feel better, does this mean they are no longer at risk for suicide?

Hopefully, if a person seems better, they are indeed feeling better and are no longer considering suicide. HOWEVER, this apparent upswing in mood could also be an indicator of an increased risk of suicide. Sometimes, a suicidal person might feel relief that they have finally come to a decision – the emotional conflict over living or dying has been resolved. The best way to determine if a person’s improved mood is related to decreased or increased risk of suicide is to have a direct and open discussion about suicide.

If a person is suicidal, does this mean they will always be suicidal?

Most suicidal people are desperately seeking a way out of unbearable emotional pain and are ambivalent about ending their own lives. After receiving help to overcome this pain, many people go on to live rewarding and meaningful lives, never again seriously contemplating suicide. For others, a current suicidal crisis may be overcome and the risk of suicide significantly lowered or eradicated for a period of time. This period of time can range from minutes, hours or days, to possibly months, or even several years.

What are the warning signs that someone might be considering suicide?

  • About 80 per cent of people who attempt or complete suicide send out warning signs to those around them, although they may not make a direct plea for help. Some warning signs may include:
  • Talking or joking about suicide or dying;
  • Making preparations for death such as giving away significant possessions, making a will, writing a suicide note, clearing up loose ends;
  • A previous suicide attempt; the suicide of someone important;
  • Being persistently depressed or down for more than a couple of weeks; protracted anxiety or agitation; extreme mood swings/bipolarity; outbursts of rage, grief, violence;
  • Isolation, withdrawal from previously enjoyed relationships and activities;
  • Lethargy, lack of interest, low energy, insomnia or over-sleeping;
  • Increased use of alcohol or drugs;
  • Uncharacteristic high risk activity, impulsive behaviours
  • Expressions of hopelessness, helplessness, purposelessness
  • Low self-esteem, low self-worth, self-contempt, anger toward self;
  • Significant loss(es), such as important relationship, health, identity, economic security, freedom.

What can we do if we think someone is suicidal?

It is important to show a potentially suicidal person that we care and that we are concerned for their safety. It is also important to directly ask the person if they are considering suicide. This shows that we are taking their feelings seriously, and helps to establish if the risk for suicide is real. If you feel uncomfortable asking, it is important that you get someone else to ask. We need to listen to the person – without judgment and by showing empathy. If the person says they are considering suicide, we need to get help for that person by enlisting the help of professionals, such as a family doctor, a mental health professional, a 24-hour crisis line, or even a hospital emergency room if the person is imminently at risk. It is also important to enlist familial, friendship and social supports. If the person is at imminent risk of harming themselves, do not leave them alone until they have been assessed and received help from a competent and trustworthy professional, or until another trustworthy adult arrives to stay with them.

Don’t suicides happen fast, and usually as the result of one sudden traumatic event, so that it is hard to prevent them?

Suicides can appear to happen fast, or “out of nowhere,” when we have not noticed any indications of a person’s suicidality. Although most people (80%) present a range of indicators to the people around them, few of us have been educated to recognize these warning signs and we miss them.

Suicides are also rarely the result of a single traumatic loss or change. Usually, there are many contributing factors and events that have developed or occurred over a period of time. A sudden traumatic event may be the ‘trigger’ event that moves a person to end their life, but it is unlikely the only cause.

It is likely that many suicides could be prevented if we educated ourselves about the immediate, short term, and long term indicators of suicidal risk, as well as how to reach out and get effective help for someone who is letting us know they are in serious distress.

What is the link between mental health and suicide?

Research suggests that 70 to 90 per cent of people who have made a lethal attempt, or died by suicide, were suffering from one or more unmanaged mental health issues – such as protracted depression or anxiety, bi-polarity, psychosis, and/or substance abuse. While the presence of an unmanaged mental health issue is strongly associated with suicide, it is important to note that most people assessed with a mental illness are not at risk of suicide, and that few suicides are wholly the result of a mental illness.

Do ‘copycat suicides’ really occur?

Yes, there is evidence to show that ‘copycat suicides’ or clustering does occur under some circumstances. If someone is already vulnerable (depressed, anxious, isolated, has made a previous attempt, and/or is showing other warning signs), one suicide can trigger another. “Copycat suicides” or “suicide contagion” is most pronounced when someone loses someone close to them. Youth also appear to be especially vulnerable. Other conditions that can increase the risk of ‘copycat suicides’ are high profile, sensational portrayals of suicide in the media, or inadvertent glorification of a suicide victim.

Get Help

Help is Available! We truly are here to listen, here to help 24 hours a day, 7 days a week. If you or someone you know is having thoughts of suicide, call 1-800-273-TALK (8255) or call your local crisis center. For those more comfortable texting, text the Crisis Text Line at 741741.


Volunteering at the Crisis Centre is a great way to make a contribution to your community. These vital programs could not exist without volunteers.

Quick Guide to Getting Started with Zero Suicide

1. Read the online Zero Suicide Toolkit

2 Challenge your organization to adopt a comprehensive approach to suicide care, using the readings and tools in the Lead section of the toolkit.

3 Convene your Zero Suicide implementation team.

4 Discuss and complete the Zero Suicide Organizational Self-Study.

5 Create a workplan and set priorities, using the Zero Suicide Workplan Template.

6 Formulate a plan to collect data to support evaluation and quality improvement using the Zero Suicide Data Elements Worksheet.

7 Announce to staff the adoption of an enhanced suicide care approach.

8 Administer the Zero Suicide Workforce Survey to all clinical and non-clinical staff to learn more about staff’s perceptions of their comfort and competence caring for those at risk for suicide.

9 Review and develop processes and policies for screening, assessment, risk formulation, treatment, and care transitions. Examine the use of electronic and/or paper health records to support these processes.

10 Evaluate progress and measure results. Revisit the Zero Suicide Organizational Self-Study to check your organization’s fidelity to the core components of Zero Suicide. Collect data on the measures you selected in Step 6.