Asking for Help
cALL 800-273-8255 or
text "sos" to 741741
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.
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:
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:
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.
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 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 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.
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:
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.
A Reactive Action
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:
Even though it is very hard to believe it in the moment of crisis, the following statements are almost always true:
Do You Know Your Level Of Suicide Risk?
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.
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?
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.
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:
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.
Prevention And Societal Measures
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:
Suicidal: Biological Contributions
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.
Suicidal: Sociocultural Contributions
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.
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.
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."
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.
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?
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 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:
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.
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
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.
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 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.
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.
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?
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 (www.befrienders.org). 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.
And On-line Self-Help Resources For Major 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
Suicide Treatment-Finding A Psychotherapist
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.
Initial Suicide Treatment Interview
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:
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:
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:
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.
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:
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.