Suicide, or killing oneself, is the ultimate act of despair. People with suicidal thoughts or behavior experience abnormally intense feelings of hopelessness in response to difficulties in life such as loss, disappointment and failure. For many, suicide becomes a permanent solution to problems that are often only temporary.

Women are more likely than men to attempt suicide. Men, on the other hand, are about four timesmore likely to die from a suicide attempt. Older adults are the highest at-risk population in the United States. Suicide among teens and young adults has declined in recent years but continues to be a troubling phenomenon.

Suicide is closely linked to major depression and impulsive behavior. Untreated major depression poses the greatest risk of suicide, although many different factors can increase a person’s risk. These include other mental illnesses (including borderline personality disorder and substance abuse), chronic or terminal physical illness and environmental factors. In particular, psychological disorders (e.g., depression, borderline personality disorder) that coexist with substance abuse pose a significant risk factor for suicidal thinking and behavior. In addition, low levels of serotonin in the brain are associated with both depression and suicidal behavior. Previous suicide attempts and a family history of suicide can also put a person at risk for suicide.

Most people who commit suicide provide some type of warning to those around them. The signs are similar to those of depression and can include a loss of interest in activities previously enjoyed, isolation and a preoccupation with death. In general, a specific plan for suicide and access to lethal methods indicate a clear danger of suicide. If the plan includes a date/time, the indication is even more clear.

Suicide prevention includes educating people to recognize and respond to the warning signs of suicide. Physical or mental health evaluations may help identify disorders related to the suicidal thoughts/behavior. Preventive treatment can include medication (e.g., antidepressants) and/or psychotherapy. In rare and severe cases, electroconvulsive therapy may be recommended. 

Suicide is the deliberate taking of one’s own life. According to the National Institute of Mental Health (NIMH), suicide was ranked as the 11^th leading cause of death in the United States in 2004, accounting for over 32,400 deaths.  Another 650,000 people receive emergency treatment every year after suicide attempts. More people die every year from suicide than from homicide.

People who wish to kill themselves often experience overpowering feelings of despair, hopelessness and isolation that cloud their judgment. Such intense feelings are considered abnormal reactions to normal events in life such as loss, disappointment, rejection or failure. Stressful events in a person’s life may trigger the extreme emotions that can lead to suicidal thoughts or behaviors.

Thinking about killing oneself is called suicidal ideation. Sometimes, but not always, these thoughts lead to suicide. It is estimated that there are eight to 25 suicide attempts for every suicide death according to NIMH. Most people with suicidal thoughts or behavior indicate their feelings or intentions to friends or family members.

Suicide is different from other types of violent self-injury in which emotional release is the objective – not death.

Suicidal thoughts and behavior appear to be the result of a combination of various components, including psychological, genetic and environmental factors. Suicide is most commonly linked to depression and substance abuse disorders.

Gender appears to play an important role in suicidal behavior. Women attempt suicide almost three times as often as men. Yet, men die from suicide four times more often than women.

This disparity apparently occurs because men and women tend to use different methods to commit suicide. Firearms are the most common method used by men. Nearly 80 percent of all firearm suicides are committed by white males, according to the National Institute of Mental Health (NIMH), and these represent almost 60 percent of all suicides. Women are more likely to attempt suicide by the ingestion of poison (including drug overdoses). Depending on the lethal quality of the poison or drug used and whether immediate help is available, this method may result in death less often than suicide by guns. This may also account for the higher number of suicide deaths in men. In countries where highly lethal poisons are readily available or treatment resources are scarce, for example, female suicides outnumber males.  

Ethnicity also appears to be associated with suicide risk. American Indians and Alaskan Natives have the highest suicide rate. Whites are at a greater risk of suicide than blacks or Hispanics. Although still lower than that of Caucasians, new findings indicate that African Americans have a higher suicide rate than previously reported. The suicide rate for African Americans (especially young men), although traditionally lower than that of whites, began to increase in the 1980s, according to NIMH.

Adults age 65 years and older face a significant risk of suicide. Of all age, gender and race groups in the United States, white men over 85 years of age have the highest rate of suicide – six times the average national rate. In 2000, according to NIMH, adults age 65 and older comprised just 13 percent of the population in the United States yet accounted for 18 percent of all suicide deaths that year.

Young people can be especially vulnerable to self-destructive emotions. They often experience strong feelings of stress, confusion, self-doubt, fear and uncertainty. Divorce or family turbulence, social isolation, academic stress or moving to a new home or school can intensify these feelings. For many of them, suicide may appear to be a solution to their problems.

Thousands of young people commit suicide every year. According to the NIMH, suicide is the third leading cause of death among 15- to 24-year-olds (after accidents and homicides), and the fourth leading cause of death for 10- to 14-year-olds. Furthermore, researchers estimate that there are between 100 to 200 suicide attempts for every successful suicide among adolescents. This is more than 10 times the corresponding for older adults. This may demonstrate that younger people may be more ambivalent about suicide.

Suicidal thoughts and behavior may be side effects of treatable illnesses. Almost all people who commit suicide had a diagnosable mental disorder at the time of their death – and many had more than one. The following are some of the most common psychiatric disorders that may include suicidal thoughts/behavior:

• Depression. A biologically based mental disorder with symptoms that include feelings of sadness, hopelessness, the inability to concentrate, and significant increases or decreases in sleep/appetite. Thoughts of suicide (suicidal ideation) are common in depression. Depression affects the body, mood and thoughts – distorting perceptions and impairing good judgment. There are several types of depression (e.g., major depression, dysthymia, bipolar disorder). Suicide is more likely to occur in people with major depression.
  
  
• Substance abuse. The use or dependence on alcohol or various prescription, over-the-counter (OTC) and/or recreational drugs. Alcohol or drug abuse can increase a person’s risk of suicidal thoughts or behavior because it can mask other disorders, such as depression. It can also decrease inhibitions and cause people to act more freely on impulses or feelings. Recent findings indicate that mental health disorders that coexist with substance abuse are significant risk factors for suicide.
  
  
• Borderline personality disorder. A personality disorder characterized by impulsivity and instability in mood, self-image and relationships. Self-injury and suicide attempts are common signs of this disorder.
  
  
• Anxiety and post-traumatic stress disorder. Post-traumatic stress disorder is an anxiety disorder where symptoms, which may include suicidal thoughts, occur after a traumatic event (e.g., personal assaults, natural disasters, accidents, acts of terrorism, military combat). Other anxiety disorders, including panic disorders, can also be related to suicide.
  
  
• Schizophrenia. A major mental illness characterized by an inability to tell reality from fantasy and often includes hallucinations or delusions. Suicidal behavior is associated with this disorder.
  
  
• Body dysmorphic disorder (BDD). Individuals with this disorder have a distorted body image and think obsessively about their appearance, often for hours at a time. A recent study indicates that people with BDD are 45 times more likely to commit suicide than people in the general population. There is controversy over determining whether deaths associated with this disorder indicate a desire to die or a result of the techniques that sufferers may use to achieve the distorted body image they desire.

A complex assortment of factors may put a person at risk for committing suicide. Age, gender, social status and even ethnic background all play a role. People over the age of 65 years, for instance, are more likely to commit suicide than any other age group. Women are at a greater risk of attempting suicide, while men have a greater risk of dying by suicide.

The most significant risk factor for suicide is untreated depression. According to the National Mental Health Association, between 30 and 70 percent of people who committed suicide suffered from major depression or bipolar disorder. People with other mental disorders (e.g., anxiety disorders) are also at higher risk for suicide.

Many mental disorders that increase the risk of suicide are interrelated. For instance, substance abuse often coexists with depression, and both are risk factors for suicidal thoughts or behavior. According to the National Institute of Mental Health (NIMH), more than 90 percent of people who committed suicide suffered from depression or another mental disorder at the time of their deaths.

Biochemical factors may increase the risk of suicide. The level of certain neurotransmitters in a person’s brain have been linked to both suicidal behavior and depression. Low levels of serotonin have been detected in people who committed or attempted suicide.  Since serotonin helps control impulsivity, a decrease in the amount of serotonin in a person’s brain may increase the risk of suicide. It may also increase the risk of depression, which can include suicidal thoughts or behavior. There is still uncertainty whether the changes in neurotransmitters cause these disorders, or reflect the presence of the disorders.

Genetics also plays a role, since suicide appears to run in families. Those with a family history of suicidal behavior are at greater risk of suicidal behavior. However, since suicide is so closely linked to a number of different mental disorders that have a genetic component, it is unclear whether it is the suicidal behavior or accompanying disorder that may be genetic.

Medical conditions can increase a person’s risk of suicide. Any physical illness that involves chronic pain or is terminal can lead to depression, which can include suicidal thoughts or behavior. These include medical conditions such as heart disease, stroke, cancer, HIV/AIDS, diabetes and Parkinson’s disease. In addition, depressive symptoms can be a side effect of various medications or a result of viral infections, thyroid disorders and low testosterone levels (in men).

A number of social or environmental factors can increase a person’s risk of suicide. These include high stress, easy access to lethal means (e.g., firearms in the home, access to potentially lethal medications or poisons) and recent loss (e.g., divorce, job, relationship, status, self-esteem). For youth, these risk factors also include physical/sexual abuse, a history of family violence and exposure to the suicide of others (contagion). For older adults, common environmental risk factors include the death of a spouse, retirement or loss of independence (e.g., moving into a nursing home).

Also closely linked to the risk of suicide are previous suicide attempts, a history of suicidal thoughts or behavior, impulsive or aggressive behavior and a lack of involvement in school, work or social activities. A history of suicide attempts appears to be the best indicator of future suicide attempts. About 50 percent of successful suicides have at least one attempt in their background. Secondary risk factors include stress and social isolation, feelings of hopelessness or vulnerability, being easily overwhelmed by stress, and/or low self-esteem.

There are many different methods to help prevent suicide in people who are identified to be at risk. Thorough physical and mental health evaluations can help determine possible causes of suicidal thoughts/behavior in order to get appropriate treatment. Any expression of suicidal thoughts should be taken seriously.  

When there is a clear, immediate risk of suicide, it is important to seek help from a physician, mental health provider, hospital emergency room or emergency services (e.g., 911). In general, the more defined a suicide plan, the greater the risk. For example, if a person has thought about how and when they will do it, and they have access to a lethal means (e.g., a gun or pills), the risk of suicide is high. Inpatient psychiatric care may be necessary when a suicidal person is a danger to him or herself.

In addition, most people who commit suicide signal their intentions to family or friends. Learning to identify and respond to these warning signs can help prevent suicide. These signs can include:

• A loss of interest in previously enjoyed activities (anhedonia)
• Preoccupation with death/suicide
• Increased social isolation
• A significant increase/decrease in sleep or appetite

Suicidal thoughts and behavior are often treated with antidepressants and/or psychotherapy. In rare cases, electroconvulsive therapy may be used.

The issue of a link between antidepressants and suicide behavior in adolescents has been explored recently. In 2004, the Food and Drug Administration (FDA) asked all manufacturers of selective serotonin reuptake inhibitor (SSRI) antidepressants to include a strong label warning indicating that antidepressants might raise the risk of suicide ideation or suicide among teens. This warning was expanded in 2007 to include adults aged 18 to 24 in the first two months of treatment. The warning is now required on all antidepressants.

It's important to note that numerous studies have shown that adults over age 25 can be effectively treated with antidepressants, and while these adolescent warnings are alarming, patients and their parents should speak to their physicians about all treatment options. Antidepressants are still recommended as treatment for adolescent depression by the American College of Neuropsychopharmacology (ACNP) and the American Academy of Child and Adolescent Psychiatry. An ACNP task force found that antidepressants remain effective, even as there was a small increase in risk of suicidality. Other studies have found that since the FDA's first warning in 2004, the prescribing rate for antidepressants among adolescents has dropped dramatically even as suicide rates have begun to creep back up again. No causal relationship has been established.

Obviously, there are many unresolved issues surrounding the use of antidepressants and adolescent suicide. The best option is to thoroughly discuss options with the prescribing physician and to closely follow the monitoring protocols established by various medical authorities if antidepressants are the best option.

There is no evidence that asking a person suspected of suicidal thoughts/behavior about it increases the likelihood that he or she will attempt suicide.  

Preparing questions in advance can help patients and their loved ones have more meaningful discussions with physicians regarding their conditions. Patients and loved ones may wish to ask the doctor the following questions about suicide:

1. Do you have experience treating people who are suicidal?
   
   
2. Someone I know may be suicidal. How can I be sure?
   
   
3. What is “suicidal behavior”? What should I do if someone I know has engaged in such behavior?
   
   
4. Is there a specific way I should approach a suicidal person? What should I do or say? What type of questions are important to ask?
   
   
5. Does my loved one have an underlying disorder that is related to his/her suicidal thoughts or behavior?
   
   
6. What do you think is causing my loved one’s suicidal thoughts or behavior?
   
   
7. Are there medications that may be appropriate for my loved one? What are their side effects?
   
   
8. Which type of psychological therapy would be most effective for my loved one?
   
   
9. Can you recommend a therapist, mental health professional, group or other setting that may benefit my loved one?
   
   
10. Would you recommend hospitalization? What are the benefits and/or risks associated with inpatient psychiatric care?
    
    
11. How can I prevent my loved one from future suicide attempts?