Suicidal Thoughts

Suicidal ideations are troubling, but help is available to stop them.

• Suicide is intentionally acting to end one's life.
• Suicide attempts may be planned out or impulsive.
• Murder-suicide involves a person killing someone else, then himself or herself. This is a very dramatic, but fortunately rare, event.
• Suicide by cop involves a person trying to provoke police officers to kill him or herself.
• Self-mutilation is deliberate self-harm without an intent to end one's life. Self-mutilation is associated with an increased risk of suicide.
• Most individuals who commit suicide have a mental illness such as depression, bipolar disorder, or schizophrenia.
• Decreased serotonin activity in the brain is associated with suicide risk.
• People who feel hopeless, helpless, or isolated are more likely to consider or attempt suicide.
• People who have serious losses -- deaths of close people, loss of jobs, a move -- are more at risk for suicide.
• Every 40 seconds, somewhere in the world, someone ends his or her life.
• In the U.S., about 100 people die every day of suicide.
• Young people and older adults are more likely to commit suicide.
• Guns are the most common method for completed suicide. Poisoning or overdose and asphyxiation/hanging are the next most common methods.
• People who have experienced bullying, physical abuse, or sexual trauma are more at risk for considering, attempting, or completing suicide.
• Treatment of mental-health conditions can reduce the risk of suicide and improve quality of life.

Suicide is most simply defined as the act of intentionally killing one's self. The word suicide may also be used to describe a person who has killed himself. Suicide is often considered a taboo subject, and people often feel uncomfortable discussing it. This sort of stigma may actually prevent individuals from telling others when they are experiencing suicidal thoughts, and it may also prevent people from asking friends and loved ones about suicidal thoughts, even when they may have concerns.

Thoughts of ending a person's own life, or of killing one's self, are also known as suicidal thoughts or suicidal ideation. Some people may plan out suicide attempts, whereas others are impulsive and in the moment.

There are other specific terms used to describe certain types or categories of suicide. Most suicides involve only a single person. Rarely, groups of people, such as members of an extreme religious sect or cult, may commit suicide together -- a mass suicide. An agreement between two or more people to commit suicide is a suicide pact. Although these are uncommon, they most often involve a husband and wife or other couple.

When a person first kills another person (or persons) and then ends his or her own life, it is called a murder-suicide. The most common murder-suicide is after a breakup or divorce, when one member of the former couple kills the other and then himself or herself. Almost all of the perpetrators are men (>90%). Even more rarely, an individual may kill many other people before committing suicide. These cases are very uncommon (less than 0.3 per 100,000 people; <3% of all suicides), but because of the dramatic and horrible loss around these events, they receive a lot of attention and coverage in the news and other media.

Suicide by cop describes a situation when someone commits a crime or threatens someone in an attempt to force police officers to kill him or her. It may be difficult to know for sure what the person intended when he or she is shot by police. Additionally, an individual's suicide in this way can greatly affect both the police involved as well as the community at large.

Euthanasia should not be confused with suicide. In euthanasia, someone, usually a doctor, makes a decision to actively end someone's life. Most often this is a patient with a terminal illness (an illness that will result in death regardless of treatment) who has been deemed to be unable to make his or her own decisions. Euthanasia is not legal in the United States, but it is considered legal in a few European countries (Belgium, Luxembourg, the Netherlands). In contrast, physician-assisted suicide refers to a doctor prescribing specific medicines that taken together are likely to result in death. Ethically, physician-assisted suicide also requires a person who can make his or her own decisions, a doctor who will serve this role, and someone who has a life-ending condition. Additionally, assisted suicide (or "assisted dying") is illegal in 46 of 50 states in the United States. Three states have laws permitting assisted suicide (OR, VT, WA) and one state permits assisted suicide based on a court ruling (MT). Internationally, the Netherlands, Belgium, Luxembourg, and Switzerland also allow assisted suicide. A broader discussion of the ethics of euthanasia and assisted death is beyond the scope of this article.

Self-mutilation, such as cutting, burning, or scratching, is deliberate self-harm usually without intending to cause death. Other common methods are hitting the head or other parts of the body, pinching, pulling hair, or picking skin. Although this common behavior is usually not considered suicidal (people usually say they aren't trying to cause death or serious harm), people who self-harm are more likely to eventually attempt suicide or even to eventually end their lives by suicide.

Parasuicide, or parasuicidal behavior, is more difficult to define. Literally, parasuicide means "like" or "near" suicide. This could include suicide attempts in which someone survives, self-mutilation, or suicide attempts in which the method is not expected to cause death.

Many people show warning signs or changes in behavior prior to a suicide attempt. While no specific behavior, or pattern of actions, can predict a suicide attempt, it is important to watch for signs and behaviors that are concerning. These warning signs parallel the risk factors described above. Changes or increases in these behaviors are particularly concerning:

• Increased use of drugs or alcohol
• Statements threatening to hurt or kill oneself
• Talking or writing about death or suicide
• Looking for access to firearms, pills, or other means for committing suicide
• Statements of hopelessness, purposelessness, helplessness/feeling trapped
• Increased anger or rage, threats of revenge
• Increased risky or reckless behavior
• Preparing a will or insurance policies; giving away important personal belongings; making arrangements for belongings, pets, etc., to be cared for.
• After a long period of depression and low energy, suddenly seems brighter or full of energy

Any of these may be concerning, but they are particularly troubling when they are paired with recent losses, including deaths, breakups, job or financial losses, or medical diagnoses. If you see these warning signs, it is critical to talk to the person openly about any concerns and get him or her connected to help.

This question is complex and difficult to answer -- our best information comes from people who have survived suicide attempts or by trying to understand what people who killed themselves may have in common. Alternately, some people leave a suicide note that may give some insight into their state of mind. Many people who attempted suicide indicate that they don't necessarily want to die but more often want to end their pain -- emotional or physical.

Most, but not all, people who commit suicide have a mental illness. This includes depression, bipolar disorder, anxiety, or schizophrenia. Additionally, mental illness also includes substance-abuse disorders. Substance-abuse disorders include alcoholism (alcohol dependence), alcohol abuse (including binge drinking), as well as dependence on or abuse of any other drug such as heroin, cocaine ("coke", "crack"), methamphetamine ("meth"), opiates/opioids (oxycodone, hydrocodone, morphine, methadone), or others. When people are using alcohol or drugs (they are drunk, high, or stoned), they can be more impulsive -- more likely to act without thinking about what might happen. Unfortunately, this is often when suicide attempts occur.

Specific symptoms of mental illness are related to suicide attempts and completed suicide. A feeling of hopelessness -- being unable to imagine that things could get better -- is common in depression and related to suicide attempts. People may also describe this as feeling trapped or out of control -- this may or may not be related to a mental illness. Sometimes these feelings can be due to being bullied, abused, raped, or put through other trauma. Helplessness, a sense that nothing can be done to change things or to solve their problems, is also commonly described. Neuroscience researchers have tried to understand what biological factors are linked to suicide. Research on suicide is closely tied to research on depression, bipolar disorder, schizophrenia, and other mental-health disorders with increased risk of suicide. The strongest evidence is linked to the serotonin system in the brain. Serotonin is a brain chemical (neurotransmitter) that is involved in mood, anxiety, and impulsivity. Serotonin levels have been found to be lower in the cerebrospinal fluid (CSF, or "spinal fluid") and brain of suicide victims. Neurotransmitters send their signals in the brain by binding to receptors, which are proteins on a nerve cell surface. Some types of serotonin receptors are also decreased.

Stress levels are also connected to suicide rates. The body's response to stress is regulated by the hypothalamic-pituitary-adrenal (HPA) system, a system that links part of the brain (hypothalamus) and parts of the endocrine (hormone) system (pituitary and adrenal glands). People who committed suicide have been found to have abnormally high activity of this stress activation system. Other brain chemicals, structures, and activity have also shown possible links to suicide, but the evidence is not as strong. There is still more that we don't understand about brain changes and suicide, but these findings point us in a direction to hopefully better treat disorders with increased risk of suicide and to possibly identify people at risk for suicide early enough to prevent attempts.

People who feel isolated or different may turn to suicide attempts as an escape. People who have experienced sexual abuse or other types of trauma are more likely to attempt suicide. Similarly, veterans of the military, especially those who have served in combat or wartime, are at increased risk of suicide.

Loss is also a reason people consider suicide. Loss could include the death of a friend, family member, or loved one. Other triggers may include a breakup, loss of a romantic relationship, a move to another place, loss of housing, a loss of privilege or status, or a loss of freedom. It could be financial losses such as losing a job, a house, or business. During times of economic problems (such as the Great Depression or the recent Great Recession), more people attempt suicide.

If someone close to you commits suicide, you may be more likely to consider or attempt suicide yourself. Groups of suicides like this, especially in teenagers or young people, are often referred to as suicide clusters or copycat suicides.

Certain religious beliefs may influence people to commit suicide. Some religions may leave people feeling guilty for things they have done and may lead them to believe they can't be forgiven. Some individuals may believe that sacrificing their lives (committing suicide for their beliefs) will earn them a reward (like going to heaven) or will be best for the religion. Some people will take their own lives for their religion (martyr themselves). Suicide bombers, often from extreme Muslim groups, are an example of this.

In some cultures, such as traditional Japan, shame or dishonor might be a reason to end your life. This type of suicide, known as hara-kiri or seppuku, traditionally involves a specific ceremony and ritual knife.

Even though suicide is a relatively common cause of deaths, it is extremely difficult to predict. People who attempt or commit suicide come from every race, country, age group, and other demographic. There are many factors that are common among people who died by suicide, but most other people with these same factors still do not attempt suicide. For example, even though most people who commit suicide have some mental disorder, such as depression, most people who have depression do not commit suicide. Even so, we can still learn about suicide, and hopefully do better at preventing suicides, by understanding risk factors.

Globally, societal and cultural factors also affect suicide risks. Communities with limited access to health care or that discourage help-seeking behavior place people at higher risk. Countries involved in war or other violent conflicts, as well as natural disasters, also tend to have higher suicide rates. Ethnic groups who are facing significant discrimination, particularly with displacement or immigration, are also at risk.

Certain demographic factors are associated with an increased suicide risk, and since they can't be changed, they are sometimes called non-modifiable risk factors. These include male gender, Caucasian ethnicity, age (under 25 or over 65), and relationship status (divorced, widowed, and single). Certain professions, such as physicians and dentists, may be more at risk for suicide. It is not clear if this is due to job stresses, knowledge of and access to lethal means, or other factors. Unemployment or recent job loss may also increase the risk of suicide attempts. Importantly, individuals with limited social supports are at higher risk of attempting suicide. Individuals with a family history of completed suicide are at higher risk of suicide themselves. This may be related to hereditary (genetic) factors but may also be due to the trauma and distress of losing a family member in this way. Lastly, one of the strongest predictors of future suicide attempts is past suicide attempts.

Social factors, including current or past discrimination, abuse, or trauma also predispose people to suicidal acts. People who have been subject to bullying are more likely to consider or attempt suicide. This is true both for young people currently being bullied, as well as adults who were bullied when younger. It is likely that more recent tactics, such as cyberbullying, would have the same impact. A similar pattern is seen for those who have been sexually abused or assaulted, both women and men. For adults sexually abused as children, suicide attempts were two to four times more likely in women and four to 11 times more likely in men, compared to those not abused. People who identify as lesbian, gay, bisexual, or transgender (LGBT) also seem to have higher rates of suicide. People exposed to combat, either civilians or military personnel, have an increased risk of suicide as well. Although these stressors are very different, they likely have a similar impact on people; people can feel isolated and helpless in controlling or escaping these situations, and they may also feel more socially isolated and unable to reach out for help.

A mental-health diagnosis is one of the most significant risk factors for suicidal thoughts or actions. Psychological autopsy studies identified one or more mental-health diagnoses in 90% of people who completed suicide. The most common diagnoses are depression (including bipolar depression), schizophrenia, or alcohol or drug dependence. The lifetime risk of suicide for individuals with these diagnoses is higher than in the general population, although reports vary from about two to 20 times the risk for the general population. Individuals diagnosed with certain personality disorders, such as antisocial, borderline, or narcissistic personality disorder, also have higher risk of suicidal thoughts or behaviors. Alcohol dependence increases the risk of suicide by 50%-70% compared to those without alcoholism. In addition, at least one-third of suicides had alcohol in their system, 20.8% had opiates (including heroin, morphine or prescription pain killers), and 23% had antidepressants. These statistics may support how common depression, alcohol abuse, and drug abuse are in those who commit suicide, however part of this may be people using these substances as part of their attempt to end their lives. Although the association between a mental-illness diagnosis and suicide risk is strong, it is important to remember that most people with mental illness do not attempt or complete suicide.

In addition to formal mental-illness diagnoses, specific symptoms -- even without a full diagnosis -- increase the risk of suicidal actions. Certain symptoms of depression, particularly hopelessness and anhedonia, are more closely tied to increased suicidal thoughts than a depression diagnosis. Hopelessness describes a feeling that things cannot change or be better than they are now. Anhedonia means an inability to enjoy anything, or to feel interested in things that would usually give pleasure. Feelings of anxiety (often also described as worry, nervousness, or fear) are also linked to suicidal thoughts. Some studies suggest that feelings of anxiety or agitation may increase how likely someone is to act on thoughts of suicide. A study of people who committed suicide after discharge from a psychiatric hospital showed that 79% expressed "extreme" or "severe" anxiety, but only 22% had suicidal thoughts.

Problems with sleep, such as insomnia, are an acute risk for suicide, whether or not they are part of a depressive episode. It is important to note that sleep problems increased the suicide risk, even after controlling for other variables such as gender, mood, and alcohol problems. Fortunately, recent studies suggest that managing sleep disorders can reduce suicide risk.

Nonpsychiatric diagnoses may also increase the risk of suicidal thoughts and actions. A wide range of medical conditions, particularly those associated with long-term (chronic) pain, a terminal (life-ending) diagnosis, or limited treatment options, have a higher risk. Some of the diagnoses shown to have a higher risk include cancer, kidney failure, rheumatoid arthritis, epilepsy (seizure disorder), AIDS, and Huntington's disease. Appropriate treatment of these conditions, and any concurrent depression, can help improve quality of life and reduce suicide risk.

Despite the wide range of suicide risk factors discussed, there are also factors that can be protective against suicide. People who have good social supports, including family members, friends, or other connections with other people, have a lower risk of suicide. Cultural groups that value family and community relationships and are close-knit tend to have fewer suicides. For men and women, having children at home, and for women, a current pregnancy, also are protective factors. Religious and spiritual practices and beliefs -- including a belief that suicide is wrong -- can also reduce suicide risks. Lastly, maintaining healthy lifestyle habits, including positive coping strategies, adequate sleep, good diet and exercise, can both maintain and improve physical and mental health, including suicide risk.

Every 40 seconds, somewhere in the world, someone ends his or her life. In 2012, there were 804,000 deaths by suicide globally, accounting for about 50% of all violent deaths in the world (1.4% of all deaths). In 2010, for the U.S. alone, there were 38,364 reported suicide deaths (about 105 suicides daily; one suicide every 14 minutes). There are more deaths due to suicide than murder (homicide) every year. More men than women die of suicide every year, although the differences vary by country. In the U.S., there are four times as many men than women who complete suicide, about 79% of all suicide deaths. In poorer countries, the difference in suicide rates between genders is lower, with a ratio of about 1 1/2 men to every woman.

Even though suicide may not be discussed as much as other issues, including murder, cancer, HIV, war, and violence, it is one of the most common causes of death. In the U.S., suicide is the 10th leading cause of death; more people kill themselves than die by murder (homicide) or other violence. Worldwide, suicides account for more deaths than wars or murders.

Suicide is more common at certain ages: People in their teens and 20s, as well as older adults, are most likely to attempt or complete suicide. Suicide is the third leading cause of death for people ages 15-24, and the second leading cause for people ages 25-34. Older men (>75 years old) have the highest suicide rates (36 deaths per 100,000 men). In women, the suicide rate is highest in those aged 45-54 (nine deaths per 100,000 women). Recently, some of these age patterns have changed, with suicide becoming more common in other age groups. From 1999-2010, suicide rates for middle-aged people (35-64) increased by 28% (from 13.7 per 100,000 in 1999 to 17.6 per 100,000 in 2010).

Suicide rates vary among different racial and ethnic groups as well; however, differences in cultural beliefs, socioeconomic status, and family structure are far more complex than these numbers would suggest. Worldwide, suicide rates vary greatly among countries and continents. In the U.S., immigrants tend to have suicide rates similar to their country of origin. In the U.S., Caucasians and Native Americans have the highest age-adjusted rates of completed suicides (15.4 or 16.4 per 100,000), while African Americans, Hispanics, and Asian-Pacific Islanders have about half this rate (5.5, 5.7, or 5.8 per 100,000).

There are many more suicide attempts than deaths by suicide. Because many attempts are not reported, estimates are likely lower than the actual number. Most reports suggest that for every suicide, there are probably at least 20-25 suicide attempts. In people ages 15-24, there may be as many as 100-200 people who survive for every completed suicide. Another statistic that is difficult to calculate is the number of people who are surviving family members, partners, or close friends of every victim of suicide -- also known as survivors of suicide. A low estimate is that at least six people are seriously affected by every suicide, which means there are about 230,000 new survivors of suicide in the U.S. every year.

For every person who attempts or completes suicide, even more have serious thoughts or plans of committing suicide. When asked about suicidal thoughts and actions in the year 2008-2009, more than 8 million U.S. adults (3.7% of the population) reported serious suicidal thoughts, 2.5 million (1% of the population) reported making a suicide plan, and 1.1 million (<0.5% of the population) reported a suicide attempt. Among younger people, over 17% of high school students (teenagers in grades 9-12; 22.4% of females and 11.6% of males) have seriously considered suicide, 13.6% made a plan (16.9% of females and 10.3% of males), and 8% (10.6% of females and 5.4% of males) reported a suicide attempt at least once in the past year. Further, 2.7% of the teenagers surveyed had a serious suicide attempt that required treatment by a doctor or nurse.

In general, men are more likely to use guns, knives, or other violent means. Women are somewhat more likely to take an overdose or some other form of poisoning. This gender difference in methods likely accounts for the higher suicide completion rate in males. Globally, limited data is available about suicide methods. The most common means in different countries are often related to what is accessible and are sometimes based on regional trends. The most extensive data on methods is from the U.S. Centers for Disease Control and Prevention (CDC) National Violent Death Reporting System.

By far, firearms are the most common method of suicide death. Over half of U.S. suicide deaths are from a self-inflicted gunshot wound. Firearms accounted for 57% of suicide deaths in men and 33% in women. It is estimated that 90% of suicide attempts with a firearm are lethal. More U.S. gun deaths are a result of suicide than homicide (in 2009, 19,000 vs. 11,500). Areas where gun ownership is higher tend to have more gun suicides. Globally, high-income countries other than the U.S. have much lower gun ownership, and suicide with firearms accounts for only 4.5% of all suicide deaths.

Deaths by hanging and suffocation (25.6%) and poisoning (including prescription drugs, street drugs, poisons, and carbon monoxide; 16.3%) are the next most common methods. Poisoning is the most common method of suicide in women, accounting for 36.5% of deaths. These three categories account for over 90% of U.S. suicide deaths in both men and women. Other less common methods include falls/jumping, motor vehicles, and cutting/stabbing.

In other countries, other means are more common. In many low-income countries with a high percentage of rural citizens, self-poisoning with pesticides is a suicide method and is thought to account for around 30% of all suicide deaths globally. Because of easy access to means, hanging is also a common method in low-income countries. In Hong Kong and China, where much of the population lives in high-rise apartments, jumping off of high buildings is a common suicide method. Use of charcoal fires for carbon monoxide poisoning has spread as a common means in China, Hong Kong, and other Asian countries over the past decade.

One of the most important, but also most difficult, tasks that mental-health professionals do on a regular basis is the suicide risk assessment. Because suicide is relatively uncommon, even in those with mental-illness diagnoses, predicting who may attempt suicide, and when, is remarkably difficult. We know from research, however, that most people who commit suicide will see a doctor or mental-health professional within the month before they end their lives. Knowing this, we must continue to work to be better at identifying those at risk.

Some professionals approach the suicide assessment by using structured interviews or rating scales to assess risk. Dr. Aaron Beck developed one of the earlier tools, the Scale of Suicidal Ideation (SSI). The SADPERSONS scale was easy to use and had fairly widespread acceptance. However, recent research showed that the SADPERSONS scale was not an accurate assessment for risk. More recently, the Columbia Suicide Severity Rating Scale (C-SSRS) has been used in a variety of settings. Validated rating scales have the advantage of being tested on many subjects and of providing an objective, often numeric score to use in making decisions. However, because suicide is a complex and low-frequency event, no scale can be completely accurate. Clinicians must still rely on good clinical judgment and account for factors not assessed in these scales.

A broader approach, integrating a detailed clinical history along with a structured interview, provides a better basis for decisions about risk. However, pressures for clinicians to see patients more quickly can limit how practical this can be. One example of an interview-based approach, which can be adapted to different clinical situations, is the Chronological Assessment of Suicide Events (the CASE approach). The goal of this approach is to get a detailed account of suicidal thoughts, preparations and attempts, along with current psychiatric symptoms to best make treatment recommendations.

For primary-care doctors, time is even more limited and must also be used to address a range of other medical issues. Screening every patient for suicide risk is impractical and has been shown to have limited value in preventing possible suicides. Current recommendations are to screen primary-care patients for depression and anxiety, and by providing appropriate treatment, suicide risk may be reduced.

There are no treatments that specifically stop suicidal thoughts. However, for each individual, identifying and treating any mental illness, and dealing with any stressors can reduce the risk of suicide. Some treatments for mental illness, including major depression and bipolar disorder, have been shown to reduce suicide risk. Certain medications have been shown to reduce the risk of suicide. Lithium (Eskalith, Lithobid), a mood-stabilizing medication used for bipolar disorder or major depression, has been shown to decrease suicides associated with depression. Similarly, clozapine (Clozaril, FazaClo), an antipsychotic medication, can reduce the risk of suicide in people with schizophrenia. It is not clear if these medications reduce suicide risk when used to treat people with other diagnoses.

In contrast, there have been concerns that antidepressants actually increase the risk of suicidal thoughts. In fact, the U.S. Food and Drug Administration (FDA) has required a warning stating that antidepressants may increase the risk of suicidal thoughts in children, teens, and adults in their 20s. There was no evidence that these medicines increased suicidal behavior in older people. This warning was based on a review of studies that suggested this increase. Some researchers and clinicians disagree with this warning and feel that not prescribing antidepressants has actually increased suicidal thoughts and attempts, since fewer people are treated for depression. Ongoing studies will hopefully answer these questions more clearly. In the meantime, it is important that people taking antidepressants know about this risk and are given information about how to get help if they have suicidal thoughts.

People who frequently have suicidal thoughts may benefit from specific types of psychotherapy ("talk therapy" or counseling). Cognitive behavioral therapy (CBT) addresses negative thoughts and cognitive distortions. Cognitive distortions are ways that the mind reads things around us in an overly negative way (for example, if someone receives a critical comment from one person, the person believes everyone thinks badly about them). By repeated practice, people can learn to overcome these thought patterns and reduce depression and suicide risk. CBT has been shown in many research studies to help improve symptoms of depression and anxiety disorders. Similarly, dialectical behavioral therapy (DBT), a type of therapy developed to help people with borderline personality disorder, also can reduce suicidality. DBT uses mindfulness and other coping skills to decrease impulsive and destructive urges that can lead to suicide attempts.

• Take statements about suicide, wanting to die or disappear, or even not wanting to live, seriously -- even if they are made in a joking manner. Don't be afraid to talk to someone about suicidal thinking; talking about it does not lead to suicide. Discussing these thoughts is the first step in getting help, treatment, or safety planning.
• Help them to get help. Encourage or even go with them to get help. Call a hotline, clinic, or mental-health clinic.
• Remove risky items from their possession or home. It is particularly important to remove any firearms. The majority of suicide deaths used a gun, and most (90%) of suicide attempts with a gun are lethal. Other risky items may include razors, knives, and sharp objects. Prescription and over-the-counter medications should be secured.
• Avoid alcohol or other drugs; these can increase impulsive actions and suicidal thoughts. Alcohol is a "depressant" because it can make depression worse on its own. Almost one-quarter of suicide victims had alcohol in their system at their deaths.
• Practice methods to "slow down." If people can distract themselves, even for a short time, the worst suicidal thoughts may pass. This could involve anything from meditation, deep breathing, listening to music, going for a walk, or being with a pet. With a partner, friend, or family member, talking or even just being there may help.
• If someone is still feeling suicidal, it may be helpful to stay with the person or to help find others to stay nearby. This type of support or suicide watch can help keep someone safe until they can get help.
• If these strategies are not working, get help now. Go to a mental-health center, an emergency room, or even call 911. Suicide hotlines may also be able to connect you to local help.
• Remember, get help -- it can get better.

Suicide affects many people, young and old, in every country and culture of the world. Almost a million lives are lost every year to suicide, with at least 10 million other suicide attempts, and 5-10 million people affected by the suicide death of someone close to them. Suicide remains one of the most frequent causes of death around the world. The impact of suicide makes prevention an important public-health priority and has been identified as a priority by the World Health Organization (WHO), as well as national, state, and local agencies.

Some things to prevent suicide are best done on an individual level, like watching for signs of suicidal thoughts and talking to those you know. However, some changes can be implemented on the community, state, and even national level:

• Restrict access to means for suicide. If highly lethal items such as pesticides, poisons, and firearms are less available, many deaths can be prevented.
• Improve access to health care, including mental-health treatment.
• Educate people about mental illness, substance abuse, and suicide.
• Work to reduce physical and sexual abuse. Advocate for reducing discrimination based on race, culture, gender, or sexual orientation. Provide support to vulnerable individuals.
• Fight stigma against mental illness and those suffering its effects.
• Support those bereaved by suicide.

• Find a support group, such as a survivors of suicide (SOS) group. It helps to know you are not alone.
• Grief is very different for everyone. Don't feel like you have to be on someone's schedule or timeline. It might take longer than you (or others) think it will.
• Get help for yourself, particularly if you have symptoms of depression or suicidal thoughts.

Myth: Discussing suicide might encourage it.

Fact: Many people worry about this, but there is no evidence to support this fear. It is important to speak openly about suicide, both to get help if you have suicidal thoughts, and to ask about suicidal thoughts in those close to you. Without open discussions about suicide, those suffering may continue to feel isolated, and are less likely to get the help they need.

Myth: The only people who are suicidal are those who have mental disorders.

Fact: Suicidal thoughts and actions indicate extreme distress and often hopelessness and unhappiness. While this may be part of a mental disorder, it isn't always. Many people with mental illness never have suicidal behavior, and not all people who commit suicide have a mental illness.

Myth: Suicidal thoughts never go away.

Fact: Increased thoughts or risk for suicide can come and go as situations and symptoms vary. Suicidal thoughts may return, but are not permanent, and suicide is not inevitable.

Myth: A suicidal person is determined to end his or her life.

Fact: People who have survived suicide attempts often state that they didn't want to die but rather didn't want to keep living with the suffering they were feeling. They are often ambivalent about living or dying. After an attempt, some people clearly indicate that they want to live on, and most people who survive an attempt do not end up ending their lives later. Access to help at the right time can prevent suicide.

Myth: There is no warning for most suicides.

Fact: When looking back, most people who committed suicide showed some signs in the things that they said or did in the weeks before. Some suicides may be impulsive and not planned out, but the signs of depression, anxiety, or substance abuse were present. It is important to understand what the warning signs are and look out for them.

Myth: Individuals who discuss suicide won't really do it.

Fact: People who talk about suicide may be reaching out for help or support. Most people aren't comfortable talking about suicide, so they might bring it up in a joking or offhand way. However, any mention of suicide should be taken seriously and viewed as an opportunity to help. Most people contemplating suicide are experiencing depression, anxiety, and hopelessness but may not have any support or treatment.

Myth: Suicide attempts are just a "cry for help" or a way to get attention.

Fact: Suicide attempts, even "minor" ones that don't require serious medical attention, are a sign of extreme distress. Suicide attempts should be taken seriously and are a reason to assess and treat any ongoing mental-health issues.

Suicide hotlines:

• National Suicide Prevention Hotline: 1-800-SUICIDE (784-2433)
• National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
  • Free, 24-hour hotline available to anyone in suicidal crisis or emotional distress
  • Military veterans suicide hotline (press 1)
  • Suicide hotline in Spanish (press 2)
• Teens can get text support from the crisis text line by texting "listen" to 741-741
• LGBT Youth Suicide Hotline: 1-866-4-U-TREVOR
• For local suicide hotlines, check this directory: http://www.suicide.org/suicide-hotlines.html

Information and resources:

• American Association of Suicidality
  • http://www.suicidology.org
  • 202-237-2280
• American Foundation for Suicide Prevention
  • http://www.afsp.org
• Survivors of Suicide (SOS) Support Groups
  • http://www.suicidology.org/suicide-survivors/sos-directory
• Brain and Behavior Research Foundation (BBRF, formerly NARSAD)
  • http://www.bbrfoundation.org
• Centers for Disease Control and Prevention (CDC)
  • Suicide prevention: http://www.cdc.gov/violenceprevention/suicide/
• Depression and Bipolar Support Alliance (DBSA)
  • Support group finder: http://www.dbsalliance.org/site/PageServer?pagename=peer_support_group_locator
• Healthy Minds (http://www.healthyminds.org)
  • Finding help -- locate mental-health providers: http://www.psychiatry.org/mental-health/key-topics/finding-help
• National Alliance on Mental Illness (NAMI) (http://www.nami.org)
  • Suicide resources: http://www.nami.org/template.cfm?template=/contentManagement/contentDisplay.cfm&contentID=23041
  • Support groups and programs: http://www.nami.org/Template.cfm?section=Find_Support
• National Institutes of Mental Health (NIMH)
  • Suicide prevention: http://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml
• Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Suicide prevention: http://www.samhsa.gov/prevention/suicide.aspx
• World Health Organization (WHO)
  • Suicide topic page: http://www.who.int/topics/suicide/en/