Clinicians may be strategically positioned to help in the fight against suicide. Studies show that 4 out of 5 people (83%) who die by suicide have had contact with a primary care physician within the last year of life (Stene-Larsen & Reneflot, 2019; Walby et al., 2018). Clinicians should be alert for suicide risk factors and should assess suicidal ideation and behavior in all patients with depression.
Risk Factors For Suicide
- Suicidal behavior: history of prior suicide attempts, aborted suicide attempts or self-injurious behavior
- Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity). Co-morbidity and recent onset of illness increase risk
- Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, insomnia, command hallucinations
- Family history: of suicide, attempts or Axis 1 psychiatric disorders requiring hospitalization
- Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame or despair (e.g., loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation.
- Change in treatment: discharge from psychiatric hospital, provider or treatment change
- Access to firearms
Uniform Suicide Terminology
The following definitions come from the Center for Disease Control and Prevention, Division of Violence Prevention (Crosby, Ortega, & Melanson, 2011) and the American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluation of Adults (APA, 2016). These terms define how we speak about suicide.
- Aborted or self-interrupted attempt: When a person begins to make steps towards making a suicide
- attempt but stops before the actual act/behavior
- Affected by Suicide: All those who feel the impact of suicidal behaviors. Including those bereaved by
- suicide, friends ,community, and/or celebrities.
- Bereaved by Suicide: Family members, friends, co-workers, others affected by the suicide of a loved one. Can be referred to as survivors of suicide loss .
- Interrupted Attempt: When a person is interrupted by other persons/outside circumstances from making a self-destructive act after making preparatory actions.
- Means: The instrument or object used to engage in self-inflicted injurious behavior with any intent to die as a result of the behavior.
- Methods: The mechanism used to engage in self-inflicted injurious behavior with any intent to die as a result of the behavior.
- Protective Factors: Factors that make it less likely that an individual will develop or engage in a suicidal
- Risk Factors: Factors that make it more likely an individual will develop or engage in suicidal behaviors.
- Safety Plan: Written list of warning signs, coping responses, supports(both lay and professional), and emergency contacts that an individual may use to avert thoughts, feelings or impulses or behaviors related to suicide, including lethal means restrictions.
- Self-directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself
- Suicidal Behaviors and/or preparatory actions: Acts and or preparation toward making a suicide attempt
- Suicidal Ideation: Thoughts of engaging in suicidal behaviors and/or serving as the agent of one’s own death.
- Suicidal Intent: Subjective expectation and desire for a self-injurious act to end in death. Evidence that at the time of injury the individual intended to kill self' and understood the consequences of the actions.
- Suicidal Plan: Delineation of the method, means, time, place, or other details for engaging in self-inflicted injurious behavior with any intent to die as a result of the behavior.
- Suicidal Thoughts: General nonspecific thoughts of wanting to end one's life.
- Suicide' Death caused by self-directed/intentioned injurious behavior with any intent to die.
- Suicide Attempt: A non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior with or without injuries.
Suicide Risk Factors
Studies show that 90%-95% of persons who die by suicide have a psychiatric illness (Litman, 1989; Schreiber & Culpepper, 2019), though there has been some recent questioning of the universality of these findings (Pompili, 2020). The psychiatric disorders most commonly associated with suicide are depression, bipolar disorder, and schizophrenia (Tidemalm et al., 2008). The severity of the psychiatric illness and any comorbidities both increase risk. Having depression along with an anxiety disorder, psychotic symptoms (e.g., paranoia, delusions, command hallucinations), personality disorder, alcoholism, or other substance use disorder increases the patient’s risk of suicide.
Mental Health Conditions Associated with Suicide
- Bipolar Disorder
- Anxiety Disorders
- Personality Disorders
- Alcoholism or Other Substance Abuse
- Post-Traumatic Stress Disorder
- Traumatic Brain Injury
Patients who have recently been discharged from an inpatient psychiatric facility are in period of very high risk for both suicide attempts and suicides (Baldessarini, 2020). A recent review found that 26.4% of suicidal acts occur within the first month after discharge, 40.8% within 3 months, and 73.2% within one year (Forte et al., 2019). Forte and colleagues (2019) write that patients “whose hospitalization was associated with suicidal behavior require particularly close evaluation and secure aftercare” (p. 214). Follow-up is critical. Studies show that follow-up contact with suicide attempters can significantly reduce the number of subsequent attempts and completions (Gould et al., 2018).
Certain medical conditions have also been associated with an increased risk for suicide. These conditions include asthma, cancer, COPD, coronary artery disease, diabetes, spinal disc disorders, stroke, and traumatic brain injury. Chronic or terminal illness puts patients at higher risk. For example, having chronic pain doubles the risk of completed suicide (Schrieber & Culpepper, 2019; Racine, 2018; Tang & Crane, 2006).
Moreover, patients with pain and an opioid use disorder are at a particularly high risk of suicide. In fact, the number of firearm suicides in this population is even greater than the number of overdose suicides. Providers should screen patients with opioid and substance use disorders for suicide risk. Providers should also educate patients and caregivers on the disinhibiting effects of alcohol and other drugs, and stress the importance of securing access to all lethal means, not just pills. Psychiatrists may want to consider asking their adolescent patients about bullying as recent studies indicate that adolescents who are bullied have a threefold higher risk of suicide attempts (Koyanogi et al., 2019).
The evidence is clear that restricting access to firearms decreases suicides. The risk of suicide is six times greater in households with guns than households without guns. The courts have affirmed that healthcare providers are permitted to ask patients about gun ownership, and counseling about gun safety is recommended by multiple medical societies, including the American Psychiatric Association and the American Academy of Family Physicians. Suicidality is often impulsive, with between 25-50% of suicides being contemplated for as little as 5 minutes. Studies show that the risk of suicide can be reduced if the firearms are kept unloaded and/or locked (Shenassa et al., 2004).
Discussions about reducing access to lethal means is particularly important when seeing military personnel and veterans. In 2018, the number of suicides among active military personnel reached an all-time high of 24.8 suicides per 100,000 service members (Department of Defense Annual Report, 2018; LaPorta, 2019). Over 60% of U.S. military suicides occur at home and involve a firearm (Pruitt et al., 2017). Ninety-five percent of military suicides involve a personally owned firearm. A recent study found that military personnel with suicidal ideation are 53% less likely to store firearm in a safe manner than those with no such history. In this same study, military personnel with recent thoughts of death or self-harm were 74% less likely to store their firearms safely (Bryan et al., 2019).
Suicide Screening Instruments and Rating Scales
In the past 10 years, some new rating scales have been developed, most notably the Columbia Suicide Severity Rating Scale (C-SSRS). The C-SSRS rates the degree of suicidal ideation on a scale, ranging from “wish to be dead” to “active suicidal ideation with specific plan and intent and behaviors.” An individual exhibiting even a single behavior identified by the scale was 8 to 10 times more likely to die by suicide (Posner et al., 2011).
The Veteran Health Administration’s newly released guidelines recommend screening for suicide risk, but they do not recommend a specific instrument, as their review of the evidence did not identify a specific instrument or method that could reliably determine risk level. They recommend instead that clinicians use several methods to evaluate suicide risk – e.g., self-report measures combined with clinical interviews (Department of Veterans Affairs, 2019; Sall et al., 2019). When the C-SSRS or any of the other rating scales is used for screening purposes, it can be accompanied by a complete and comprehensive suicide risk assessment to arrive at a clinical judgment determining level of risk (Fochtmann & Jacobs, 2015; Jacobs, 2016).
Examples of Suicide Assessment Instruments
Suicidal ideation and suicidal behavior warrant thorough assessment (APA, 2003; Fochtmann & Jacobs, 2015). In addition, “[t]he goal of the suicide assessment is to identify factors that may increase or decrease a patient’s level of suicide risk, to estimate the overall level of risk, and to develop a treatment plan that addresses patient safety and modifiable contributors to risk…” (APA, 2003; Fochtmann & Jacobs, 2015, p. 491).
Suicide Risk Assessment
The suicide assessment is conducted through direct questioning and observation. The mental health professional obtains information about the patient’s presenting problem, recent and past psychiatric history, medical history, current mental state, and suicidal thinking and behavior.
Purpose of Suicide Risk Assessment
- Identify factors that may increase or decrease suicide risk
- Address immediate safety needs
- Develop a differential diagnosis to guide treatment
The extensiveness of suicide assessments will vary, depending on the setting, the patient’s capacity or willingness to provide information, the patient’s mental state, and the availability of information from previous contacts with the patient and collateral sources (e.g., family members, medical records, other mental health professionals) (Jacobs, 2016).
What Clinical Situations Warrant a Suicide Assessment?
- Intake Evaluations
- Emergency Department or Crisis Evaluations
- Depressed People anticipating or experiencing significant loss or stress (e.g., divorce, financial loss, legal problems, personal shame or humiliation)
- Physical Illnesses (particularly if life threatening, disfiguring, or associated with severe pain or loss of function)
- Pertinent Clinical Change (Increase in suicide ideation, suicidal behavior, change in mental status)
In 2016, the APA Work Group on Psychiatric Evaluation formulated practice guidelines for suicide risk assessment during the initial psychiatric evaluation. They recommend that a suicide risk assessment cover the following areas of inquiry:
- Current suicidal ideas, suicide plans, and suicide intent
- Prior suicidal ideas, suicide plans, and suicide attempts
- Prior intentional self-injury in which there was no suicidal intent
- Current aggressive or psychotic ideas
- Mood, level of anxiety, thought content and process, and perception and cognition.
- Anxiety symptoms, including panic attacks
- Past and current psychiatric diagnoses
- History of psychiatric hospitalization and emergency department visits for psychiatric issues
- Current or recent substance use disorder or change in use of alcohol/or other substances
- Presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational, interpersonal/relationship problems, lack of social support, or painful, disfiguring or terminal illness)
- Trauma history
Additional Areas of Inquiry in the Event of Current Suicidal Ideation
- Patient’s intended course of action, if current symptoms worsen
- Access to suicide methods, including firearms
- Patient’s possible motivation for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations)
- Reasons for living (e.g., responsibility to children, religious beliefs)
- Quality and strength of the therapeutic alliance
- History of suicidal behaviors in biological relatives
The Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) is a suicide assessment protocol for use by mental health professionals. It was originally conceived by Douglas Jacobs, MD, and it drew upon the American Psychiatric Association’s Practice Guidelines for the Assessment and Treatment of Suicide Risk. The SAFE-T is used by clinicians to help compile the detailed information needed to assess a patient’s suicide risk.
The Five Steps of the SAFE-T
- Identify Risk Factors
- Identify Protective Factors
- Conduct Suicide Inquiry
- Determine Risk Level/ intervention
Identify Risk Factors
- Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
- Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, cluster B personality disorders, conduct disorder
- Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations
- Family history: of suicide, attempts, or Axis I psychiatric disorders requiring hospitalization
- Precipitants. Stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g., loss of relationship, financial or health status – real or anticipated). Ongoing medical illness (especially CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation.
- Change in treatment: Discharge from psychiatric hospital, clinician, or treatment change.
- Access to firearms
Primary Precipitants for Suicide
- Relationship Problems
- Interpersonal Conflicts
- Recent Crises
Identify Protective Factors
- Internal: ability to cope with stress, religious beliefs, frustration tolerance
- External: responsibility to children or beloved pets, positive therapeutic relationships, social supports
Please note that protective factors, even if present, may not counteract significant acute suicide risk.
It is important to identify the risk factors, though you cannot use risk factors (either alone or in combination) to predict suicide in an individual. However, knowing that a particular risk factor or factors may increase the patient’s likelihood of suicide is an important component of the suicide assessment. It helps you to devise an individualized treatment plan, such as putting the patient on a particular medication or hospitalizing the patient to reduce suicide risk (Jacobs, 2016).
The Suicide Inquiry
- The suicide inquiry involves specific questioning about suicidal thoughts, plans, behaviors, and intent. You begin by determining whether there is suicidal ideation present. You can start with a broad question, such as “Have you had thoughts of death?” or “Are you thinking about killing yourself?”
- For patients with suicidal ideation, it is important to inquire about access to lethal means, especially firearms, and whether or not a plan is present. If the patient has access to firearms, clinicians should discuss with the patient (and potentially family members and other household contacts) the importance of restricting access or removing the firearm from the home.
How to Ask About Suicide
- Ask in a way that is natural and flows with the conversation
- Do not ask as though you are looking for a “no” answer
- Treat the interview as an exploration, not as a checklist
- Remain calm
- Listen more than you speak
- Maintain eye contact
- Engender confidence that there are alternatives to suicide
- Adopt a collaborative stance, reflecting empathy and genuineness
- Use supportive and encouraging comments
- Do not argue
- Use open body language
- Limit questions to gathering information casually
- Express an understanding of the patient’s desire to relieve intolerable pain
(Jha, 2016 in Yasgur, 2016)
- Ideation– frequency, intensity, duration – in last 48 hours, past month, worst ever
- Plan- timing, location, lethality, availability, preparatory acts
- Behaviors – past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. NSSI
- Intent – extent to which the patient (1) expects to carry out the plan and (2) believes the plan to be lethal vs. self-injurious. Explore ambivalence: reasons to die vs. reasons to live.
- For Youth: Ask parent/ guardian about evidence of suicidal thoughts, plans, or behaviors and changes in mood, behaviors, or disposition
When a pediatric patient screens positive for suicide risk
The National Institute of Mental Health (NIMH) has developed a Brief Suicide Safety Assessment Guide to be used with patients aged 10-24 years-old.
The patient can be interviewed together with a parent/guardian, if available. If the patient is 18 years of age or older, the patient’s permission is needed for the parent/guardian to join in the interview. Then, the parent/guardian can also be involved in creating a safety plan for managing suicidal thoughts that may arise in the future.
This NIMH guide for assessing pediatric patients can be accessed at https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/outpatient/brief-suicide-safety-assessment-guide.shtml
Determination of Risk Level
Assessment of risk level is based on clinical judgment.
Those judged to be at high risk for suicide may be those who have made a potentially lethal suicide attempt or have strong intent. High risk patients also tend to have psychiatric disorders with severe symptoms or an acute precipitating event. In contrast, those deemed to be at low risk for suicide may have thoughts of death, but no plan, intent, or behavior. Low risk patients often have modifiable risk factors and strong protective factors (Jacobs, 2016).
In determining the overall level of risk, the clinician can assess the patient’s judgment, ability to control impulses, and ability to comply with treatment (Jacobs, Brewer, & Klein-Benheim, 1999).
Determining the Intervention
To Determine the Level of Intervention
- Estimate the acuteness or chronicity of the patient’s suicidality
- Evaluate competence, impulsivity, and acting out
- Assess the therapeutic alliance
- Plan the nature and frequency of reassessments
(Jacobs et al., 1999, pp. 35-36)
Hospitalization does frequently occur after a suicide attempt or interrupted/aborted attempt.
Indications for Hospital Admission after a Suicide Attempt
- The patient is psychotic
- The patient is impulsive
- The patient is severely agitated
- The patient has poor judgment
- The patient had lethal intent
- The attempt was premeditated
- Precaution was taken to avoid rescue or discovery
- The patient regrets surviving
Guidelines for Inpatient Suicide Assessments
When a patient is admitted to a hospital for suicidality, a complete psychiatric evaluation and suicide assessment will determine the level of observation. For suicidal inpatients, observation levels range from checks every 15 or 30 minutes to continuous (1:1) observation. The evaluation and assessment also assesses the level of restriction (e.g., supervised bathroom use, restriction to the unit or to public areas, supervised sharps, and placement in hospital clothing).
Frequency of Reassessment
When Are Psychiatric Inpatients assessed for Suicide Risk?
- On admission
- Prior to increasing privileges or granting a pass
- When there is a change in mental status
- At discharge
Suicide risk is highest in the 12 months following a hospital discharge. A recent review article found that the rate of suicide in the year following hospitalization was 16 times that found in the general population and that one-third of the 12-month risk occurred in the first two weeks (Baldessarini et al., 2019; Forte et al., 2019). These findings support the value of follow-up with patients post discharge.
Follow-up means checking in with those who have recently experienced a suicide crisis to assess their well bring and level of risk, as well as to support them in their recovery. Follow-up can be in a variety of forms (e.g., phone calls, emails, texts, letters, office visits, home visits, step-down programs). There is evidence that follow-up after initial contacts for suicidal ideation and after discharge from emergency departments and inpatient settings can save lives (Fleishman, 2008; Gould et al., 2018; Motto & Bostrom, 2001; Vaiva et al., 2006; While et al., 2012).
Documentation concludes each suicide assessment. The clinician should document the assessed suicide risk level and the rationale for the determination of risk level. The clinician should also document the intervention that will be used to try to reduce suicide risk as well as the plan for follow-up treatment.
What Should Documentation Include?
- Assessed Level of Risk and Rationale for this Risk Level
- Treatment Planto Reduce Current Risk (e.g., medication, psychotherapy, ECT, contact with significant others, consultation, firearms instructions)
- Plans for Follow-up Treatment
The FDA has approved many medicines for treatment of depression, notably the antidepressants. Antidepressants can reduce suicidal thoughts in patients with depression, along with other aspects of improvement, but they require time to take effect. Most people experience significant improvement within 3 months of antidepressant, usually with some benefit within the first month.
The currently most frequently prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). They are effective, have a favorable side-effect profile, and are unlikely to be lethal on overdose. Examples of SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). Other types of antidepressants include modern serotonin and noradrenaline reuptake inhibitors (SNRIs, such as venlafaxine), tricyclics (such as amitriptyline, desipramine, imipramine, and nortriptyline), monoamine oxidase inhibitors (MAOIs; such as phenelzine and tranylcypromine), inhibitors of neuronal uptake of both serotonin and noradrenaline reuptake inhibitors (such as duloxetine, levo-milnacipran, and venlafaxine) and some with other action mechanisms (such as bupropion and mirtazapine).
Antidepressants require taking the medicine consistently and at adequate doses. Some symptoms may improve in the first few weeks, but antidepressants can take up to three months to achieve clinically appreciable benefits, even when the right medication is given at the right dose.
Common reasons why some people may not experience improvement with antidepressant treatment
- The drug was not suited for this person, who needs a different kind of medication
- Not taking the medication at the right time or missing doses
- An additional therapy is required (such as psychotherapy, ECT, rTMS, or ketamine, or addition of lithium or a second-generation antipsychotic such as aripiprazole, lurasidone, or quetiapine).
There is inconsistent evidence about effects of antidepressant treatment and suicidal risks. One would expect that treatments that are effective for depression should reduce suicidal risk. However, compelling evidence of reduction of rates of suicide attempt and suicide during antidepressant treatment is lacking, although suicidal ideation typically decreases, usually along with improvement of other symptoms of depression. Some patients may become excited, irritable, sleepless, and so are potentially more suicidal during treatment with antidepressants. Moreover, the FDA requires all antidepressants to carry a black-box (severe) warning that persons under age 25 years may experience new or increased thoughts of suicide, especially when first starting treatment. Careful monitoring of suicidal status in patients taking an antidepressant is important to detect early clinical changes that may lead to increased suicidal risk, but also because antidepressants can unmask previously undiagnosed bipolar disorder, which requires a different treatment approach.
Important Warnings about Medicines for Depression
Call a doctor right away if you notice these changes in yourself or someone else taking medicines for depression.
- Think about dying or killing yourself
- Try to injure or kill yourself
- Feel depressed or your depression is getting worse
- Feel anxious or your anxiety is getting worse
- Have panic attacks
- Become preoccupied with exaggerated fears about health, finances or other vulnerabilities
- Have trouble sleeping (insomnia)
- Feel very agitated or restless
- Feel or act irritable, angry, aggressive, or violent
- Act on potentially dangerous impulses, such as erratic or aggressive driving
- Talk more or become more active than is normal for you (possible hypomania)
- Notice other things in your behavior or mood that are not typical for you
Lithium: Researchers found that long-term maintenance treatment with lithium reduces the risk of suicide in patients with bipolar I disorder, bipolar II disorder, and possibly unipolar depressive disorder. In bipolar disorder patients, suicide risk during lithium treatment maintenance therapy became similar to that in the general population (Tondo & Baldessarini, 2009). Lithium may provide this benefit by reducing dysphoric-agitated symptoms, aggression, and impulsivity. Lithium is given cautiously as amounts that are three or more times the typical or standard dose can be toxic or even lethal.
There is also evidence that lithium may be superior to other mood stabilizing agents in reducing suicide attempts in bipolar patients, notably compared to carbamazepine or valproate (Baldessarini & Tondo, 2009). A recent study found that juveniles being treated with lithium had half as many suicide attempts, improved depressive symptoms, less psychosocial impairment, and less aggression (Hafeman et al., 2019).
Ketamine: Low intravenous doses of ketamine can rapidly reduce suicidal thoughts even in patients with otherwise treatment-resistant depression (Wilkinson et al., 2018) and have had greater reduction of suicidal thoughts than low-doses of the sedative midazolam (Grunebaum et al., 2017). Reduction in suicidal thoughts after ketamine lasted as long as 6 weeks, with additional improvements in depressed mood and fatigue. Ketamine is administered under the medical supervision of a physician, which can be as prolonged as two hours per treatment with intranasal esketamine.
Clozapine: Approximately 50% of patients who have schizophrenia or schizoaffective disorder attempt suicide, and about 10% die of suicide. Clozapine is the only medication approved by the FDA for suicide prevention in patients with schizophrenia. It is used to treat severe schizophrenia symptoms in those who have not been helped by other medications, but also for those who have tried to kill themselves and are likely to try again, regardless of their previous responses to treatment. Clozapine is only available through a restricted distribution and monitoring program to limit risks of potentially lethal aganulocytosis.
Clozapine is an old drug but widely considered to be the first of a class designated as "second-generation" or atypical antipsychotics, reflecting their far lower risk of adverse neurological effects that were typical of the early antipsychotics, including the phenothiazines and haloperidol. Clozapine produces complex changes in brain chemistry and its special status as one of the most effective treatments for psychotic illness remains unexplained.
Evidence that treatment of schizophrenia patients with clozapine substantially reduces their risk of suicidal behavior is quite secure (Masuda et al., 2019), including a randomized trial comparing it to olanzapine (Melzer et al., 2003). There is no evidence that clozapine treatment reduces suicidal risk in depressive disorders and it remains poorly studied in bipolar disorder
Psychotherapy is often used to treat persons who have suicidal thoughts or who have made suicide attempts. Methods with the most scientific evidence are cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), and mindfulness-based cognitive therapy (MBCT). These behavioral psychotherapies can be used in conjunction with medication treatment.
The presence of hopelessness is a significant risk factor for suicide, even in the absence of sufficient evidence to diagnose clinical depression. Most psychotherapeutic interventions approach suicidal patients with efforts to manage hopelessness.
Cognitive Behavioral Therapy (CBT): A recent review article found that CBT can reduce suicidal ideation, attempts, and hopelessness, based on efforts to change thinking and behavioral patterns (D’Anci et al., 2019). The therapist and patient work together to understand the problems identified and to develop a treatment strategy. The goal is to build skills to better cope with distress. CBT appears to be especially effective in reducing suicidal behavior when the treatment specifically targets suicidal thoughts and behaviors (as opposed to depression or mental illness in general).
Dialectical Behavioral Therapy (DBT): DBT combines methods of CBT with skills-training and mindfulness meditation techniques to improve emotion regulation, interpersonal relationships, and ability to tolerate distress. DBT was developed in the early 1990s by Linehan as a treatment for suicidal behavior in women with borderline personality disorder (BPD), but has since shown effectiveness for other disorders, including mood, eating, substance misuse, and PTSD.
Several recent studies have found DBT to be an effective treatment for reducing repeat suicide attempts in highly suicidal patients, including adolescents (McCauley et al., 2018). A cornerstone of DBT is the idea that the patient must build a life worth living, even when the patient has many problems and wishes to die.
Mindfulness-Based Cognitive Therapy (MBCT): This form of psychotherapy integrates mindfulness meditation practices and cognitive therapy techniques. A growing body of evidence indicates that training in mindfulness can help to break down the link between depressive symptoms and suicidal thinking in addition, MBCT can protect against depressive relapses that are common in those with a history of suicidal ideation and behaviors (Barnhofer et al., 2015).
Brain Stimulation Techniques
Electroconvulsive Therapy (ECT): Electroconvulsive Therapy (ECT) is one of the most effective treatments for patients with treatment-resistant depression or severe depression with psychotic features. It involves applying a brief electrical stimulation to the brain to induce a generalized seizure, while a patient is under anesthesia and given a muscle-relaxant to avoid injury. In the United States, most ECT is now given on an outpatient basis. ECT is used for severe cases when other treatments (including medication and psychotherapy) have failed to yield adequate responses.
ECT is also used for suicidal patients who require a rapid treatment intervention. ECT can rapidly reduce suicidal ideation (Watson, 2019). Over 60% of patients with major depressive disorder achieve remission by the third week of treatment with ECT, though many experience relapse within the following 6 months. Accordingly, most people treated with ECT require some form of maintenance treatment (e.g., psychotherapy, medication, additional ECT)—not surprising for lifelong, recurring illnesses.
Repeated Transcranial Magnetic Stimulation (rTMS): Repeated Transcranial Magnetic Stimulation (rTMS) is sometimes used to treat patients with major depressive disorder who do not respond to one or more adequate trials of antidepressants. rTMS uses magnetic stimulation to activate selective brain sites without inducing a generalized seizure.
rTMS may resolve suicidal ideation in some patients with treatment-resistant depression. In one study, bilateral, left-unilateral, and sham rTMS was evaluated for effects on suicidal ideation (Weissman et al., 2018). Suicidal ideation resolved in 40.4% of patients exposed to bilateral rTMS, 26.8% with left-unilateral rTMS, and 18.8% with sham rTMS, indicating superiority of bilateral treatment.
Although rTMS does not seem to be as effective as ECT, it does not require anesthesia and has far less adverse effects on memory and cognition, and bilateral rTMS may be a useful alternative treatment for suicidal ideation when ECT is declined, not tolerated, or not readily available.
Magnetic Seizure Therapy (MST): In this relatively new intervention for patients with treatment-resistant depression, a therapeutic seizure is induced by magnetic stimulation of the brain at higher frequencies than are used in rTMS. Patients given MST are anesthetized and given a muscle-relaxant to avoid injury similar to the protocol for ECT. MST can reduce suicidal ideation in some patients with treatment-resistant depression: in one study 44.4% of patients treated with MST experienced resolution of suicidal ideation (Sun et al., 2018).
Suicide during the Perinatal Period
One of the DSM-V changes that came out in 2013 is the use of the term “perinatal depression” as opposed to “postpartum depression.” The diagnosis of perinatal depression requires that the depression occurs during the pregnancy or during the first four weeks postpartum. The diagnostic criteria did not change in DSM-V; the time period for the relevant symptoms was extended (Stuart-Parrigon & Stuart, 2014).
Suicidal ideation and suicides are more likely to occur during the pregnancy than postpartum (Mauri et al., 2012; Orsolini et al., 2016). Pregnant women are more likely than the general population to endorse suicidal ideation. The prevalence rate of suicidal ideation during pregnancy varies from 3-33%, depending on the study and where it was conducted. Women living in urban areas have higher rates of suicidal ideation during pregnancy than women living in rural or suburban communities (Gelaye, Kajeepeta, & Williams, 2016). Pregnant teens with limited social support are at more than double the risk of having suicidal ideation (Coelho et al., 2014). Other risk factors for suicidal ideation during pregnancy are being age 20 or younger, having fewer than 12 years of education, exposure to intimate partner violence, and a history of major depressive disorder (Ghandi et al., 2006; Gelaye et al., 2016).
However, while pregnant women are more likely than the general population to experience suicidal ideation, they are less likely than their non-pregnant counterparts to die by suicide (Gelaye et al., 2016). This finding holds both in the United States and abroad (Appelby, 1991; Gissler et al., 2005; Gelaye et al., 2016; Marzuk et al., 1997; Samadari et al., 2011). Nevertheless, suicidal ideation and attempts during pregnancy have been associated with adverse consequences, including low birth weight (Gelaye et al., 2016; Ghandi et al., 2016). In one study, infants born to mothers who reported depressive symptoms which included suicidal ideation weighed 239.5 grams less on average than infant born to mothers who reported depressive symptoms without suicidal ideation (Gelaye et al., 2016; Hodgkinson et al., 2010).
The suicide rate among women who have given birth in the last year is also significantly lower than the suicide rate among women who have not given birth. Nevertheless, suicide still occurs in postpartum women and, in fact, is one of the most common causes of maternal death in the year following delivery, accounting for about 20% of postpartum deaths (Lindahl, Pearson, & Colpe, 2005; Wisner et al., 2013). Bodnar-Deren and colleagues (2016) found that of the 2.2% of women who screened positive for suicidal ideation in the first 6 months postpartum, 8% had true suicidal intent and required emergency psychiatric care. Women with postpartum psychiatric hospitalizations are 70 times more likely to die by suicide during the first postpartum year than women who do not have a postpartum psychiatric hospitalization (Appleby et al., 1998; Oates, 2003; Orsolini et al., 2016).
Risk Factors for Suicide in the Perinatal Period
- Younger Maternal Age
- Unpartnered Relationship Status
- Unplanned Pregnancy
- Non-Caucasian Race
- Shorter Psychiatric Illness Duration
- Preexisting Psychiatric Illness
- Current Psychiatric Diagnosis
Postpartum Psychosis: Postpartum psychosis is relatively rare. It occurs in about 1-2 in 1000 deliveries (Lukyx et al., 2019), compared to postpartum depression which occurs in 1 in 9 women (CDC; Ko et al., 2017). Symptoms of postpartum psychosis include delusions or strange beliefs, hallucinations, feeling very irritated, hyperactivity, decreased need for or inability to sleep, paranoia or suspiciousness, rapid mood swings, and difficulty communicating at times (https://www.postpartum.net/learn-more/postpartum-psychosis/). Women with this diagnosis often do not express their suicidal or infanticidal thoughts (Lukyx, et al, 2019).
Approximately 5% of women with postpartum psychosis ultimately die by suicide (Lucchesi, 2018). Suicide is uncommon during the immediate postpartum psychosis, but becomes more common during subsequent psychotic episodes and later in life (Brockington, 2017). The rate of infanticide in women with a history of postpartum psychosis is 4% (Lucchesi, 2018).
The most significant risk factors for postpartum psychosis are a previous psychiatric episode and a personal or family history of bipolar disorder. There is an increased incidence of suicide among first-degree relatives of women with postpartum psychosis. Approximately one out every three women (31%) who experience postpartum psychosis with a pregnancy will experience a relapse with subsequent pregnancies (Bergink, Rasgon, & Wisner, 2016).
It is imperative that women with postpartum psychosis receive immediate treatment. Literature reviews show that both lithium and ECT can be effective for postpartum psychosis. Inpatient care is usually required (Bergink et al., 2016).
Perinatal Screening: There are variety of recommendations. Orsolini and colleagues (2016), for example, recommend that women be screened during the prenatal period – and particularly during pregnancy – for thoughts of harming oneself and thoughts of harming infants. Pregnant women should be asked about their own and their family mental health history. Mothers should be monitored and supported for a full year following their delivery.
The American Academy of Pediatrics (AAP) recommends that pediatricians screen mothers for depression at the baby’s one-, two-, and four-month visits. The AAP recommends using either the Edinburgh Postnatal Depression Scale (EPDS) or a two-question screen (Stuart-Parrigon & Stuart, 2014).
The American College of Obstetrics and Gynecology (ACOG) recommends all perinatal women be screened at least once during the perinatal period for both depression and anxiety, but does not endorse any specific instruments. In addition, even if the woman had been screened during pregnancy, she should be screened again during the comprehensive postpartum visit. Women with current depression or anxiety, a history of perinatal mood disorders, risk factors for perinatal mood disorders, or suicidal ideation require close monitoring, evaluation, and assessment.
The risk of both first onset and recurrence of bipolar disorder is increased during the postpartum period. A study published in JAMA Psychiatry found that nearly a quarter (22.6%) of the postpartum women who screened positive for depression in their study had bipolar disorder (Wisner et al., 2013). This percentage is likely to be an underestimate as the instrument they used, the EPDS, did not specifically screen for hypomania or mania. Clinicians should take a careful history to determine if the depression they find on a screen is actually the depressed phase of a bipolar disorder, as bipolar depression requires a different form of treatment than unipolar depression. Antidepressants can worsen bipolar disorder (Sharma et al., 2009; Wisner et al., 2013), and treating bipolar patients with a mood stabilizer plus an antidepressant does not confer any added benefit over treating with only a mood stabilizer (Sachs et al., 2007; Wisner et al., 2013).
While many mothers may prefer not to use medication in perinatal period, there is now a sufficient amount data to suggest that, especially in the case of severe depression, it is more beneficial for both the mother and child for the depression to be treated. “If effective structured psychotherapies are not available, medication is a recommended treatment outcome” for depression that occurs while a woman is pregnant or breastfeeding (Stuart-Parrigon & Stuart, 2014, p. 9).
- Try and do things that help me feel better for at least 30 minutes (e.g., have a bath, phone a friend, walk the dog, or listen to music).
- Write down individual negative thoughts and provide an alternative response that changes the perspective.
- If suicidal thoughts continue, I will call my emergency contact person who is ______ at _______.
- If that person is not available, I will call the 24-hour crisis line at: ______ or the 1-800-273-TALK Line.
- If I still feel suicidal and out of control, I will go to the nearest hospital emergency department.
The term “postvention” was coined in 1972 by Edwin Schneidman, the founder of the nation’s first comprehensive suicide prevention center (Schneidman, 1973). The term refers to interventions that are conducted after a suicide death to support those who have been affected, including family, friends, coworkers, and classmates. Those grieving a suicide often receive less community support for their loss than those grieving deaths by other means, which can lead to isolation (Pitman et al., 2014). One of the main purposes of postvention is to offer comfort and support to the bereaved.
One in every 5 people (21.8%) report exposure to a suicide during their lifetime (Andriessen et al., 2017). Those who have been exposed to a suicide are at a significantly increased risk of suicide. For example, those exposed to the suicide death of a first degree relative are 3 times more likely to die by suicide themselves. Those whose spouses died by suicide have between 3 and 16 times the risk (Agerbo, 2005). Men who have been exposed to suicide in the workplace are 3.5 times more likely to die by suicide than men who had not been exposed to suicide in the workplace (Hedstrom, Liu, & Nordvik, 2008).
One study found that 4.5-7.5 immediate family members and 15-20 extended family, friends, and colleagues are “intimately and directed affected” by a suicide (Berman, 2011). Those who were emotionally close to the deceased are more likely to require support and intervention following a suicide. One study found an increased incidence of depression, anxiety, and post-traumatic stress disorder (PTSD) in adolescents exposed to the suicide of a peer (Brent et al., 1996). Another study found that, without early intervention, a significant proportion of prepubertal children who had lost a sibling or a relative to suicide were likely to go on to develop major depression and/or PTSD (Pfeffer et al., 1997).
Research shows that those who knew about the deceased’s suicide plans are at greater risk of PTSD and depression, and that those who had witnessed the suicide or viewed the scene afterward are at greater risk of PTSD and anxiety (Brent et al., 1996). Adverse mental health outcomes following a suicide are also more common among those who have a psychiatric disorder or who have a family history of psychiatric disorder, particularly mood disorders (Andriessen et al., 2019; Pitman et al., 2016).
Mental Health Effects of Suicide Exposure
- Partners have an increased risk of suicide
- Coworkers have increased risk of suicide
- Parents have an increased risk of psychiatric admission
- Mothers have an increased risk of suicide after adult child’s suicide
- Children have an increased risk of depression after suicide of a parent
- Peers have increased risk of depression, anxiety, and PTSD
- Those who knew about plan have increased risk of PTSD and depression
- Those who witnessed the suicide have greater risk of PTSD and anxiety
- Relatives report more rejection and shame
Those Most Likely to Need Support
- Those emotionally close to the deceased (e.g., friends and family members)
- People who were already depressed and possibly suicidal before the death
- Those who might psychologically identify with the deceased (similar in lifestyle, values, or life circumstances)
- Family members and peers who were aware or suspicious of the plans
- Members of the community who might have felt responsible for the wellbeing of the deceased and for preventing the suicide (e.g., teachers, coaches, school counselors)
- Supervisors and colleagues in the deceased’s workplace
(Berkowitz et al., 2011)
The goals of postvention are to assist with the grieving process, stabilize the environment, reduce the risk of contagion or suicide clusters, and identify and treat mental health problems among survivors (Berkowitz et al., 2011). Studies show that as many as 5% of adolescent suicide deaths are due to contagion or imitation (Insel & Gould, 2008; Gould & Kramer, 2011).
Goals of Postvention
- Assist the grieving process
- Stabilize the environment
- Reduce the risk of contagion and suicide clusters
- Identify and treat mental health problems among survivors
(Berkowitz et al., 2011)
Postvention can take many forms. Individual and group counseling might be recommended. Many schools and colleges have plans for proceeding in the aftermath of a student suicide. Regardless of the setting, providers typically emphasize that suicide is multifactorial, not the result of a single factor or event. Providers stress the relationship between mental illness and suicide, pointing out that nearly all (90%) suicides are associated with a psychiatric disorder. They will also emphasize that there are alternatives to suicide when one is feeling depressed and hopeless, that suicide is a permanent solution to a temporary problem, and that there resources available in the community for getting help. Providers also use the forum to provide psychoeducation on grieving, depression, PTSD, suicide, and means reduction (Berkowitz et al., 2011).
Andriessen and colleagues (2019) examined the effectiveness of interventions for people who had been bereaved through suicide. They found that the most promising interventions were those that were led by a trained facilitator, that included supportive, therapeutic, and educational approaches, and that met regularly for an appropriate period of time.
Benefits of Postvention
- Provide comfort to survivors
- Reduce the risk of suicide contagion
- Provide psychoeducation on grieving, depression, PTSD, and suicide
- Case finding/screening for mental health disorders
- Means reduction – reducing access to the methods by which suicides may occur
(Berkowitz et al., 2011)
Physicians should also be alert for signs of suicidality in themselves and in their colleagues, not just in their patients. The rate of suicide among physicians is 28-40/100,000, which is double the rate in the general population. In fact, according to a recent presentation at the American Psychiatric Association conference, physicians have the highest rate of suicide of any profession. The rate of suicide among physicians is even higher than the rate of suicide among military personnel. The rate is also high among other health care professionals, including nurses, dentists, and veterinarians (Hawton et al., 2011; Tomasi et al., 2019).
Although depression appears to afflict physicians at rates similar to that of the general population, the suicide rate is significantly higher in physicians, and especially among female physicians. Unlike the gender gap in the general population, female physicians have a completion rate equal to that of their male colleagues. Having knowledge of and access to lethal substances may account for the higher rate of suicide completion among doctors.
Medical students and physicians experience significant stress, including high demands, competitiveness, long hours, and lack of sleep. These may contribute to alcohol and substance abuse, which are known risk factors for suicide. Between 10% and 15% of physicians report alcohol or substance abuse compared with 9% of the general population. A 2016 study published in JAMA found that 27.2% of medical students reported depressive symptoms and 11.1% reported suicidal thoughts (Rotenstein et al., 2016). Of the 954 medical students who screened positive for depression, only 15% sought out psychiatric treatment (Hoffman & Kunzmann, 2018; Rotenstein et al., 2016). Stigma is an obstacle to seeking treatment. Half of female doctors completing a Facebook questionnaire reported meeting criteria for a mental disorder, but said that they were reluctant to seek professional help because of the fear of stigma (Gold, 2016).
Resources for Health Care Providers
- AAP Clinical Report—Incorporating Recognition and Management of Perinatal and Postpartum Depression into Pediatric Practice
- ACOG Committee Opinion: Screening for Perinatal Depression
- The Joint Commission Suicide Prevention Portal
- Patient Safety Bundle—Maternal Mental Health: Depression and Anxiety from the Council on Patient Safety in Women’s Health Care
The sources for this website come from academic journals and books and organizations, such as the CDC, NIMH, WHO, APA, AAP, ACOG, AFSP, MHA, and NAMI. See our complete list of references.
Stop A Suicide Today provides suicide risk questions, connection to and identification of crisis resources, and information about suicide and its treatment for the public and clinicians. The Stop A Suicide Today program is not itself a health care provider. Scoring positive on the suicide risk questions is not synonymous with a clinical assessment of suicide risk. Suicide risk can be determined only by a complete evaluation performed by a health care clinician. It is recommended that anyone who either scores positive on the suicide risk questions or continues to have concerns about suicide in themselves or a loved one contact the National Suicide Prevention Lifeline 1-800-273-8255, go to a health care clinician or local emergency department for an evaluation, or call 911 for emergency assistance.