Suicide is usually preventable. Eight out of 10 suicidal persons give some sign of their intentions, according to the National Mental Health Association. Learning to recognize and respond to these signs is the first step in getting help to the person at risk. Proper screening for potential physical or psychological causes of the suicidal thoughts/behavior is also important. Most people who commit suicide have a mental or emotional disorder – major depression is the most common. These disorders are treatable.

Warning signs of suicide are similar to those of depression. These may consist of statements, directly (“I wish I was dead”) or indirectly (“You won’t need to worry about me”) about death/suicide. Specific behavior to look out for includes social withdrawal, substance abuse, giving away personal belongings or saying goodbye. Recent findings indicate that mental health disorders that coexist with substance abuse are major risk factors for suicide. Significant changes in mood, appetite and sleeping patterns can also indicate a suicide risk.

Treatment for suicidal thoughts or behavior often includes medication to treat any accompanying disorder. Antidepressants are most commonly used, although they may take weeks to work. Successful treatment of a co-occurring disorder, such as depression, depends on the regular and appropriate use of prescribed medications.

Psychotherapy is also used to treat suicidal tendencies, and can include cognitive behavior therapy or interpersonal therapy. The most effective course of treatment is a combination of therapy and medication. In cases where medication cannot be taken or does not seem to work, electroconvulsive therapy is sometimes used.

Friends and family of a suicidal person may have to intervene in the event a loved one poses an immediate danger to himself or herself. This can include contacting a physician, mental health provider, hospital emergency room or emergency services (e.g., 911). Inpatient psychiatric care may sometimes be necessary.

Suicide is a serious and usually preventable public health problem. In 1999, the U.S. Surgeon General issued a call to action to prevent suicide. It identified suicide as a significant public health problem and recommended action in three key areas: increasing public awareness, promoting intervention strategies and enhancing research surrounding suicide. This focus on information, intervention and research continues to guide the nation’s efforts in suicide prevention.

Every year, more than 500,000 Americans attempt suicide and over 30,000 die, according to the National Mental Health Association (NMHA). The disparity between attempts and deaths may be even larger because not all people who attempt suicide seek professional help afterward.

The best predictor for future suicidal behavior is a past history of a suicide attempt. For example, women are 80 times more likely and men are 200 times more likely to commit suicide in the year following an attempt, according to the NMHA. Expression of suicidal thoughts is associated with suicide attempts. Those who talk about suicide or threaten to commit suicide are 30 times more likely to kill themselves, according to the NMHA.

Increasing awareness about suicide, its warning signs and available resources is vital to prevent suicide, as well as treating the underlying illness. Often, people who suffer from depression or have suicidal thoughts are embarrassed to discuss them, or they do not have the energy or motivation to seek help. Understanding that suicide is preventable can lead to increased efforts to aid those who express suicidal thoughts or behavior.

Screening for suicidal thoughts/behavior in primary care settings is another important way suicide can be prevented. Many people who committed suicide visited their physician within six months of their death. By recognizing the signs of suicidal thoughts or behavior, primary care physicians are in a position to get their patients the help they need. Early and accurate diagnosis of any accompanying mental disorders, such as depression, will enable appropriate treatment to begin immediately. In addition, outreach for depressed men, a group less likely to seek help, may help prevent suicide as well.

Suicide intervention may include contacting emergency services (e.g, 911) when necessary. This is important if a suicide attempt has already been made or when a person poses an immediate danger to himself or herself. Also, there are two national, toll-free suicide prevention call centers that specialize in providing immediate counseling for those thinking about suicide. The phone lines are operated 24 hours a day, seven days a week:

• 1-800-SUICIDE (National Hopeline Network)
• 1-800-273-TALK (National Suicide Prevention Lifeline)

Not all suicide attempts are preceded with a warning. However, most occur with at least some type of outward signal to friends or family members. It is important to take these warning signs seriously. People who talk about suicide or call crisis centers are more likely to kill themselves.

In addition, most suicidal people have mixed feelings about death. Even severely depressed people can go back and forth between wanting to live and die. This hesitation may provide an opportunity for intervention. It may be a chance to get the suicidal person the help he or she needs.    

A person’s intent to commit suicide can be assessed in several ways. A well-defined plan, a set time or date for the suicide, access to lethal means (such as a gun, razor, knife or medication), and a lack of interest in and planning for the future can indicate severe and immediate danger of suicide.

Many of the signs of suicidal thoughts or behavior are similar to those of major depression. They include:

• Intense mood swings

• Loss of interest in previously enjoyable activities (anhedonia)
  
  
• Sleeplessness or increased sleeping patterns
  
  
• Significant increase or decrease in appetite
  
  
• Agitation, restlessness
  
  
• Fatigue, loss of energy
  
  
• Inability to concentrate
  
  
• Increased feelings of guilt, shame, worthlessness, self-hatred
  
  
• Hopelessness, as evidenced by statements such as:
  
  
• I don’t care anymore
  
  
• It will never get better
  
  
• I’ll always feel this way
  
  
• I can’t see any way out
  
  
• Preoccupation or talk of death/suicide, such as:
  
  
• I wish I was dead
  
  
• I’m going to kill myself
  
  
• You won’t need to worry about me much longer
  
  
• Withdrawal and increased isolation from people and/or activities
  
  
• Neglect of personal appearance and/or hygiene
  
  
• Putting affairs in order, like:
  
  
• Writing a will
  
  
• Saying goodbye as if people will not be seen again
  
  
• Giving away personal belongings
  
  
• Sudden cheerfulness after a bout of depression
  
  
• Discontinued use of prescribed medicine
  
  
• Discontinued visits to mental health provider or physician
  
  
• Risky behavior, such as:
  
  
• Buying/handling a gun
  
  
• Driving recklessly
  
  
• Drug or alcohol use (recent findings indicate that mental illnesses that coexist with substance abuse are significant risk factors for suicide)

Medication is often necessary to treat any mental disorders that accompany the suicidal thoughts or behaviors. Because the most common underlying disorder is major depression, antidepressants are commonly used. Lithium and mood stabilizers may also be prescribed to treat depressive symptoms. Antipsychotic or anti-anxiety medications may be used, depending on the accompanying disorder. For example, the U.S. Food and Drug Administration (FDA) has indicated that the medication clozapine may be effective in preventing suicide attempts in people with schizophrenia.

The most common antidepressants used to treat suicidal thoughts and/or behavior include the selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) and other serotonin and norepinephrine reuptake inhibitors (SNRIs). Each affects neurotransmitters in the brain associated with depression and suicidal behaviors.

When selecting an antidepressant, it is important to remember that these medications work differently for different people and all can cause side effects. Side effects can include sleepiness, dry mouth, rapid heartbeat, nausea, restlessness, headache, insomnia, sexual dysfunction and weight gain, depending upon the choice of medication.

In addition, it may take anywhere from two to eight weeks to begin to see results. Taking medications regularly is important. Suicidal thoughts/behavior may recur if medications are taken irregularly or stopped too soon.

In many cases, medication is most effective when used in conjunction with psychotherapy. Various forms of therapy can help prevent suicide by teaching the suicidal person problem-solving or coping skills as well as helping them develop a social support system. Two common psychotherapies used to prevent suicidal thoughts and behaviors are:

• Cognitive behavior therapy (CBT). Understanding the connection between thoughts and actions. This therapy can help change negative thought and behavior patterns that can lead to suicide.
  
  
• Interpersonal therapy (IPT). Therapy that focuses on a person’s relationships with others. This type of therapy can help a suicidal person work through troubled relationships.

In very rare cases, electroconvulsive therapy (ECT) may be recommended by some physicians to treat suicidal behaviors. ECT is a treatment in which electrical current is used to cause a brief convulsion in the patient. ECT can be very effective for the treatment of major depression and may exert its effects more rapidly than medications. ECT is usually considered when medication and other therapy are not effective or cannot help the patient quickly enough.

Regular visits to a physician or mental health professional, and the appropriate use of prescribed medication are the most important components of treating suicidal thoughts/behavior. A common misconception is that once a suicidal person is undergoing treatment and seems to be getting better, he or she is no longer at risk of suicide. However, treatment sometimes provides a suicidal person with the energy needed to complete the suicide. Also, when a person is resigned to death, this acceptance can release anxiety and provide the appearance that the person is getting better. Keeping appointments and taking medication regularly are especially important for the person at risk.

Certain social factors can offer some protection against suicide. Family/community support, problem-solving and conflict-resolution skills, and cultural/religious beliefs against suicide all reduce the risk of suicide. By developing these factors, people with suicidal thoughts or behavior may be able to lessen their suicide risk.

For those struggling with suicidal thoughts or behavior, the following activities can supplement their drug or psychological therapy and help distract them from thoughts of suicide:

• Develop a safety plan. For use when considering suicide or in crisis. This plan should include a list of personal triggers or signs of suicide, when to seek help and contact information. It can also include a commitment to take medications appropriately and/or attend treatment sessions and reminders that life is valuable.
  
  
• Use crisis hotlines when necessary. National and local suicide prevention call centers with specially trained staff are designed to provide immediate help and support for those considering suicide. There are two national, toll-free lines that are operated 24 hours a day, seven days a week: 1-800-SUICIDE (National Hopeline Network) and 1-800-273-TALK (National Suicide Prevention Lifeline).
  
  
• Build a support system. Talking to friends, family members, doctors or religious leaders can help prevent isolation and allow emotional expression. Participate in support groups if available.
  
  
• Remove lethal means. Removing guns, knives, razors or medications from the home can lessen the likelihood of a suicide attempt. If an overdose is planned, keep only small amounts of medication in the home or in a locked drawer.
  
  
• Develop a routine. Maintain consistent times for everyday activities (e.g., waking up, going to sleep, eating and exercising).
  
  
• Engage in positive, self-soothing behaviors. These can include deep breathing, hot baths, eating favorite foods or going for a walk. Journaling can be a healthy way to record thoughts and feelings, including things in life that are valuable and appreciated.
  
  
• Get involved in life. Engage in pleasurable daily activities, such as going to the movies, visiting a museum or knitting. Social interaction, such as enjoying these activities with others, is very important.
  
  
• Avoid drug and alcohol use. These substances may loosen inhibitions, making a person more impulsive and increasing the risk of suicidal thoughts/behavior.
  
  
• Learn about possible underlying disorders. Get as much information as possible about depression, substance abuse or any other possible disorders accompanying the suicidal thoughts/behavior.

Friends and family can offer support to a loved one with signs of suicidal thoughts or behavior. Direct, open communication is most important. Though it is commonly believed that talking about suicide can provoke suicidal behavior, this does not appear to be true. Talking usually decreases the risk of suicide because it provides an opportunity for the person suspected of suicidal thoughts/behavior to share his or her feelings and provides assurance that somebody cares. This type of open, honest communication can be extremely valuable for the person at risk.

Suicide can be a difficult subject to discuss. Here are some tips when approaching a loved one about suicide:

• Be supportive and empathetic. Listen to their concerns in a nonjudgmental way. Restraining shock, judgment or disapproval will help those with suicidal tendencies to open up and express themselves. Arguments or demands don’t help, but compassionate understanding does.
  
  
• Take them seriously. Engaging a suicidal person in open, honest communication about his or her feelings can illustrate your concern. Asking direct questions may be the only way to assess the immediate risk of suicide. Questions to ask a potentially suicidal person include:
  
  
• Do you think that life is not worth living?
  
  
• Are you thinking about hurting yourself?
  
  
• Are you thinking about suicide?
  
  
• Have you tried it before? What happened then?
  
  
• Have you thought about how you would do it?
  
  
• Do you have the means to do it?
  
  
• Do you know when you would do it?
  
  
• Is there anything that would hold you back?  Family, friends, religious beliefs?
  
  
• Would you be willing to talk to someone if you felt desperate?
  
  
• Get help immediately. Encourage anyone with suicidal thoughts or behavior to see a mental health professional for evaluation and treatment. Contact emergency services (e.g., 911) if the person is an immediate danger to himself or herself, or if a suicide attempt has been made. If necessary, drive the suicidal person to the nearest hospital emergency room.
  
  
• Offer guidance. Suicidal people may not have the energy or motivation to seek help by themselves. Provide gentle but persistent guidance. Do not leave them alone. Offer to accompany them, make appointments or help sort through any necessary insurance or healthcare paperwork.

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

1. I’ve thought about committing suicide in the past, but I no longer think about it. Do I still need to seek help?
   
   
2. Are there medications that may be appropriate for me? What are their side effects?
   
   
3. How long do I need to remain on medication?
   
   
4. What type of mental health therapy would be most effective for me?
   
   
5. Can you recommend a therapist, mental health professional, group or other setting that may benefit me?
   
   
6. Would you recommend hospitalization? What are the benefits and/or risks associated with inpatient psychiatric care?
   
   
7. What can I do to lessen my risk of suicidal thoughts or behavior? Are there changes I can make to my environment that would help?

Friends and family of suicidal persons may wish to ask their doctor the following questions about suicide prevention::

1. Someone I know may be suicidal. How can I be sure?
   
   
2. Is there a specific way I should approach a suicidal person? What should I do or say? What types of questions are important to ask?
   
   
3. If someone I know has expressed suicidal thoughts, what type of help do they need? How can I help?
   
   
4. What is “suicidal behavior”? What should I do if someone I know has done this?
   
   
5. Is it appropriate to call 911 or the police if someone I know refuses to get help for suicidal behavior? When is it appropriate?
   
   
6. Should I be concerned about the risk of suicide once someone I know is in treatment? For how long should I be concerned?