Suicide is the 10th leading cause of death in the United States. () It’s a complex problem with significant economic and human costs to individuals, families, and communities, and it's a public health crisis.
According to the Centers for Disease Control and Prevention (CDC), suicide rates rose by nearly 33 percent between 1999 and 2019, with a small decrease observed in 2019. (1)
While certain mental health conditions raise the risk of suicide, the desire to end one’s life is rarely caused by any one thing. And while there are risk factors that can help identify people in need of extra support, and sometimes there are warning signs, all too often suicide seems to come out of nowhere. One reason is that diagnosing suicide risk isn’t as simple as performing a wellness check. And the red flags, if there are any at all, can be very subtle.
Defining the Problem
While most people understand the term “suicide” to mean voluntarily or intentionally taking one’s own life, the decision to stop living is one that people arrive at in many different ways. To increase understanding of what counts as suicidal behavior and to avoid confusion when discussing an individual’s self-harming behaviors, the CDC report titled “Self-Directed Violence Surveillance” recommends using the following terminology: (2)
- Self-directed violence?Behavior directed at oneself that deliberately results in injury, or potential injury, to oneself.
- Nonsuicidal self-directed violence?This includes behavior that is self-directed and intended to cause injury or has the potential to cause injury, but for which there is no evidence, implicit or explicit, of suicidal intent.
- Suicidal self-directed violence?This includes behavior that is self-directed and intended to cause injury or has the potential to cause injury, with evidence, implicit or explicit, of suicidal intent.
- Undetermined self-directed violence?Behavior that is self-directed and intended to cause injury to oneself, but evidence of suicidal intent is unclear.
- Suicide attempt?A nonfatal self-directed injurious behavior with an attempt to die. A suicide attempt is not always successful.
- Interrupted self-directed violence?A person takes steps to injure themselves but stops or is stopped by another person.
Some people may not have attempted self-directed violence but think about doing so. This is called suicidal thought or ideation. Suicidal thoughts can be: (3)
- Passive?A person has thoughts of death but no desire or plan to harm themselves. This often looks like thoughts about one’s own death, thoughts that one would be better off dead, indifference about life, or a passive wish to die, like wanting to sleep forever or wishing for a disease or accident. Although passive suicidal ideation may not be imminently dangerous, it can still be harmful over time, as it could lead to reckless behavior or progress to more active thoughts of suicide.
- Active A person has suicidal thoughts and at least some kind of plan to act on them. Active suicidal thoughts exist on a spectrum and can range from wanting to end one’s own life to coming up with ideas about how to do this and forming an actual plan.
Prevalence in the U.S.
According to the CDC, more than 47,500 Americans died by suicide in 2019 — the most recent year for which data is available. (1) In the same year, men died by suicide 3.63 times as often as women, and white men accounted for more than 69 percent of suicide deaths, per the American Foundation for Suicide Prevention. (4)
Despite increased awareness and prevention efforts, suicide rates remain high. It’s recommended that high-risk people who verbalize suicidal thinking, make attempts, or are in a crisis that may lead to suicidal behavior receive mental health services. But such services are not a guaranteed preventive measure. By treating suicide as a public health issue, we can increase mental health services, as well as other preventive measures that address the population as a whole.
Who Is at Risk?
Many factors contribute to suicide among people with and without known mental health conditions. Generally speaking, the more risk factors an individual has, the higher their risk.
According to the?National Alliance on Mental Illness (NAMI), approximately one in five adults experience mental illness in a given year. (5) Though not all people who die by suicide were previously diagnosed with a mental disorder, there is a link between suicide and mental illness. (5)
When someone is experiencing a depressive episode, a combination of biological and psychological factors may cause feelings of helplessness that make it difficult to envision a more positive past or future.
Research shows that?alcohol use disorder?is one of the strongest predictors of suicide. People with substance use disorders are about six times more likely to die by suicide than the general population. (6) Older individuals with an addiction, individuals with both an addiction and a history of previous suicide attempts, heroin users, and those who abuse?sedatives?are at higher risk within the addiction population. (6)
According to the CDC, a family history of suicide increases one’s odds of dying by suicide. (7)
Childhood trauma and abuse can be a predictor of suicidal thoughts. A 2017 study published in the journal?Psychiatry Investigation, for example, found a strong correlation between childhood sexual abuse and suicidal ideation in adults. (8)
The CDC lists several other factors associated with suicide. (7) These include:
- Relationship problems
- Problematic substance use
- Physical health issues or serious illnesses
- Job and financial problems
- Difficulty accessing healthcare
- Criminal legal problems
- Unsafe media depictions of suicide
Young people are especially at risk for suicidal thoughts and behavior. According to the CDC, suicide is the second leading cause of death among young people between the ages of 10 and 34. (1)
If a child or adolescent has a number of risk factors, it’s imperative to get treatment early. Suicide can often be prevented if proper supports are quickly put in place. Among the risk factors that can affect young people are: (9)
- A recent or serious loss such as the death of a family member, friend, or pet. It can also include a relationship breakup, the separation or divorce of parents, loss of a home, or financial problems affecting a family
- A psychiatric disorder, particularly depression or a traumatic-stress related disorder
- Previous suicide attempts
- Alcohol and other substance abuse disorders and other high-risk behaviors
- Family history of suicide
- Access to lethal means such as a firearm
- History of trauma such as physical or sexual abuse
- Social isolation or a lack of social support
Struggling with sexual orientation in an environment that isn’t supportive is an additional risk factor for suicide among youth. Lesbian, gay, and bisexual youth seriously consider suicide at three times the rate of heterosexual youth, according to the Trevor Project, a suicide prevention organization for LGBTQ+ youth. (10) Each incident of harassment or abuse endured by lesbian, gay, bisexual, or transgender youth increases their risk of self-harm by an average of 2.5 times. (10)
Between 2007 and 2017, the rate of suicide among Black youth increased faster than that of any other racial or ethnic group. (11) A report from the Congressional Black Caucus Emergency Task Force on Black Youth Suicide and Mental Health states that Black youth under age 13 are two times as likely to die by suicide as their white peers. (11) Along with traditional risk factors, Black youth face additional risk factors, such as strain associated with racism and discrimination. (11)
A study published in 2017 in the?American Journal of Preventive Medicine?found a link between increased social media use among young adults and increased social isolation. While causation remains unclear, the study found that participants who spent more than two hours a day on social media had twice the odds of perceived social isolation than those who spent a half hour a day or less. (12)
Social media can be beneficial in bringing together people who might otherwise struggle, for a variety of reasons, to make daily connections, but it may become a risk factor if it's used as a replacement for human relationships.
What Is Suicide Contagion?
Suicide contagion is a term used when the suicide of one person or multiple people triggers an increase in suicidal behavior among others. This can affect all people, at any age, but it is particularly concerning for people who already have suicidal thoughts, have made previous suicide attempts, or have other risk factors for suicide.
A study published in the journal?PLoS One in?February 2018 found a nearly 10 percent increase in suicides following the suicide of the actor Robin Williams in 2014. Males and people between ages 30 and 44 showed the greatest increase during this time period. (13)
When a celebrity dies by suicide, the media is flooded with articles and reports about the death. This can include sensationalized information and specific details. The coverage can trigger people who are already experiencing suicidal thoughts to identify with the celebrity.
For that reason, media, public health, and suicide prevention organizations have developed “Recommendations for Reporting on Suicide” to address concerns about suicide contagion and establish best practices for news coverage related to suicide. (14) These include avoiding oversimplifying or speculating on the reason for the suicide, and not describing or depicting the method or the location where the death took place.
Signs of Suicidal Behavior
People are often cautioned to look for the “red flags” for suicidal behavior. It’s important to understand that not all people show warning signs, and the signs can be hard to detect. For instance, someone seriously contemplating suicide won’t necessarily say something direct like, “I’m thinking about killing myself.” It’s more likely they will say something indirect like, “You’ll be better off when I’m gone.”
At the same time, some people do engage in behaviors that suggest imminent danger. Get immediate help if someone is researching ways to commit suicide or gathering the lethal means to attempt suicide, such as guns or medications that can cause death at high doses. Putting one’s affairs in order or giving away prized possessions can also be signs of suicidal ideation.
Other red flags to consider include: (9)
- Communicating feelings of hopelessness
- Talking about wanting to die
- Talking about being a burden to others
- Talking about feeling trapped
- Talking about feeling unbearable pain
- Increased substance abuse
- Acting unusually anxious, agitated, or reckless
- Significant mood swings
- Increased anger or rage
- Withdrawing or feeling isolated
- Changes in sleep patterns (too much or too little)
Any warning signs should be taken seriously in adults and children. Do not assume that someone who talks about feeling hopeless or wanting to die is simply seeking attention. Each warning sign shows that a person is struggling and needs to get help quickly.
Prevention and Intervention
From a public health perspective, comprehensive programs in the community, in school systems, and in the workplace play an important role in educating people about suicide and preventing suicide.
Accessible and affordable treatment for all age groups improves the likelihood that people will seek help when they need it.
When people have a better understanding of the risk factors and warning signs and they have access to services, they are more likely to reach out for help for themselves or others.
On an individual level, open communication about suicide and mental health as well as unconditional support are essential steps to keeping a friend or loved one safe. If you sense that someone is at risk, follow these steps.
Ask Specific Questions
Asking if someone is thinking of ending their own life does not increase the likelihood that they will attempt suicide. In fact, direct communication relieves the burden of hiding complex emotions out of fear of judgment or stigma. It can provide a feeling of relief from isolation.
Be direct and listen carefully to the answers. Your friend or loved one needs to feel heard and understood. Try starting the conversation with these questions:
- “Are you having thoughts of suicide?”
- “Have you had thoughts of suicide in the past?”
- “When did you begin feeling this way?”
- “How can I help you through this difficult time?”
- “Have you considered getting help? What steps have you taken to get help?”
It’s important to listen without judgment and convey empathy. You might not know exactly how your friend is feeling, but you can understand that they need a listening ear, emotional support, and warmth during a difficult time.
Avoid statements like “You have so much to live for!” or “How can you possibly be thinking of this?” Remarks like these can trigger feelings of shame and cause further isolation.
Create a Help Plan
It can be difficult for people experiencing suicidal thoughts to connect to mental health professionals and services on their own.
One way you can help is to gather a list of resources for treatment, such as the names of licensed psychotherapists or?psychiatrists, as well as other services that can assist with?personal care needs and with getting to and from appointments.
Enact a Safety Plan
If you think that your friend or loved one is showing signs of imminent danger, even if you’re not certain, take the following precautions:
- Stay with the at-risk person until help arrives.
- Remove all lethal means.
- Take the person to the nearest hospital or call 911.
Where Can You Get Help?
There are a number of resources to help people who are suicidal or show risk factors for suicide. The starting point depends on the risk level.
- Help and chat lines: The National Suicide Prevention Lifeline (800-273-8255) and the Crisis Text Line (text HOME to 741741) provide free and confidential support and assist individuals in crisis with local resources.
- Cognitive behavioral therapy and dialectical behavior therapy are both recommended treatments for people experiencing suicidal ideation.
- Some people experiencing suicidal ideation need medication. A licensed psychiatrist (a child or adolescent psychiatrist for young people) can complete a full workup and prescribe medications.
- Call 911 in the event of imminent risk.
- To learn more about preventing suicide, visit the National Suicide Prevention Lifeline website BeThe1To.
Suicide is complex, but it is often preventable. If individuals and communities work together to increase awareness, educate one another, and mobilize local resources, they can help people who are experiencing suicidal thoughts to get the help they need.
Resources We Love
National Institute of Mental Health: Frequently Asked Questions About Suicide
This resource discusses risk factors and warning signs for suicide, as well as treatment options for people at risk of suicide.
American Foundation for Suicide Prevention (AFSP)
This organization is dedicated to raising awareness about mental health and suicide prevention, as well as funding research related to suicide and prevention. The AFSP provides resources for anyone having thoughts of suicide, and offers a search tool for suicideloss support groups in your area.
This “Conversation Documentary” about suicide prevention features the psychiatrist Mark Goulston, MD, Kevin Hines, who survived a suicide attempt, and the singer Rayko.
The Trevor Project Lifeline
The leading suicide prevention organization for LGTBQ+ people under age 25, the Trevor Project offers a lifeline for people having thoughts of suicide. Reach their helpline at any time by dialing 866-488-7386, or text “START” to 678-678 to speak with a Trevor counselor.
Suicide Prevention Resource Center: Resources for Black and African Americans
This organization provides news and resources related to suicide prevention among Black and African American people. Check out their resources on the impact of the COVID-19 pandemic on suicide rates and how racism affects mental health among Black women.
Editorial Sources and Fact-Checking
- Suicide Prevention: Facts About Suicide. Centers for Disease Control and Prevention. August 30, 2021.
- Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements.?Centers for Disease Control and Prevention. February 2011.
- Estavillo M. The Difference Between Passive and Active Suicide Ideation. Biltmore Psychology and Counseling. September 1, 2020.
- Suicide Statistics. American Foundation for Suicide Prevention. February 19, 2021.
- Mental Health by the Numbers.?National Alliance on Mental Illness. March 2021.
- Dragisic T, Dickov A, et al. Drug Addiction as Risk for Suicide Attempts.?Materia Sociomedica. June 2015.
- Suicide Prevention: Risk and Protective Factors. Centers for Disease Control and Prevention. May 13, 2021.
- Bahk YC, Jang SK, et al. The Relationship Between Childhood Trauma and Suicidal Ideation: Role of Maltreatment and Potential Mediators.?Psychiatry Investigation. January 2017.
- Suicide and Suicidal Thoughts: Symptoms & Causes. Mayo Clinic. October 8, 2018.
- Facts About Suicide. The Trevor Project.
- Watson Coleman B, et al. Ring the Alarm: The Crisis of Black Youth Suicide in America. Congressional Black Caucus Emergency Task Force on Black Youth Suicide and Mental Health.
- Primack BA, Shensa A, et al. Social Media Use and Perceived Social Isolation Among Young Adults in the U.S.?American Journal of Preventive Medicine.?March 2017.
- Fink DS, Santaella-Tenorio J, Keyes KM. Increase in Suicides the Months After the Death of Robin Williams in the U.S.?PLoS One. February 7, 2018.
- Recommendations for Reporting on Suicide.?ReportingonSuicide.org.