• Arpit Sharma

Understanding suicidal thoughts

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Suicide Overview

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 another 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.

Warning sign before a suicide attempt

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:

  1. Increased use of drugs or alcohol

  2. Statements threatening to hurt or kill oneself

  3. Talking or writing about death or suicide

  4. Looking for access to firearms, pills, or other means for committing suicide

  5. Statements of hopelessness, purposelessness, helplessness/feeling trapped

  6. Increased anger or rage, threats of revenge

  7. Increased risky or reckless behavior

  8. 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.

Treating suicidal thoughts

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 a 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.

Helping someone with suicidal thoughts

  1. 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.

  2. Help them to get help. Encourage or even go with them to get help. Call a hotline, clinic, or mental health clinic.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. Remember, get help -- it can get better.


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