Depression: Suicide

Overview.

Suicide is a tragic outcome for some people who experience depression.  Many people who attempt or die by suicide do so in response to symptoms of depression, which can generate a sense of profound hopelessness.  Having thoughts of being better off dead or of wanting to kill oneself is called suicidal ideation and is a symptom of depression.  Although having thoughts of suicide is not uncommon in the general population (3.7%), suicide attempts are much less common (.5%) and death by suicide is even more rare (.01%).  Among people with a diagnosis of depression, these numbers are much higher. Thus, it is important to remember that there is a strong link between suicide and depression and receiving effective treatment for depression is one of the best ways to reduce risk for suicide.

Risk Factors and Warning Signs

There are several signs that may signal a person is suicidal.  First, researchers have identified several “risk factors” for suicide. Risk factors are characteristics that indicate a given person is more likely to attempt or commit suicide.  Second, many people who are suicidal show “warning signs” that they are at increased risk for suicide.  Common risk factors and warning signs are:

Risk Factors

Warning Signs

  • History of suicide attempts
  • Current depression diagnosis or other mental health problem
  • Substance use
  • Impulsive or aggressive tendencies
  • Recent loss (relational, social, work or financial)
  • Low social support
  • Access to firearms
  • Increased talk of wanting to die and having no reason to live
  • Increased alcohol or substance use
  • Increased reckless or impulsive behavior
  • Saying goodbye to people and giving away valuable possessions
  • Worsening depressive symptoms or other mental illness symptoms.

Detection

Although suicide is difficult—if not impossible—to predict, healthcare professionals use a variety of different assessment tools to assess for and detect suicide.  One of the most common approaches to detecting suicide is by having patients complete self-report measures that specifically ask about suicide.  For example, the Patient Health Questionnaire-9 is a self-report measure that specifically asks patients about suicide along with other symptoms of depression. When patients endorse feeling suicidal, qualified health professionals are required by law to ask more questions to determine a person’s level of suicide risk.  The Columbia Suicide Severity Rating Scale is an interview guide that some health professionals use to guide this assessment.  Common questions to assess level of suicide risk include:

  • Have you wished you were dead or wished you could go to sleep and not wake up?
  • Have you had these thoughts and had some intention of acting on them?
  • Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Occasional thoughts of death or dying such as “It would be easier if I weren’t here” or “What if I didn’t wake up tomorrow” are relatively common among people who are depressed. Frequent thoughts of suicide, having a plan about how to kill oneself and/or having a strong desire to die are relatively less common and signal a higher level of risk for suicide. If a person is concerned about suicidal thoughts, it is best to err on the side of caution and discuss the thoughts with a mental health professional.

Interventions

Given that nearly 90% of people who die by suicide have a diagnosis of a mental disorder, one of the best ways to prevent suicide is to find effective mental health treatment.  There are many psychotherapies and medications that can effectively treat depression and help to reduce risk for suicide.  Dialectical Behavior Therapy is a type of psychotherapy that has been shown to help people who are at high risk for suicide.

Involuntary Hospitalization

Understandably, one of the biggest concerns many people have about suicide is the possibility of being hospitalized involuntarily.  This can happen when a qualified health professional places a person in an inpatient hospital facility without the person’s consent because the health care provider believes the person is at immediate risk of dying by suicide. Countries and states have slightly different laws and regulations that determine the specific details of involuntary hospitalization.  In the United States, the maximum time for an initial involuntary hospitalization is 3 to 5 days.

When someone is hospitalized involuntarily, they are sent to an emergency room or psychiatric ward where a health professional will conduct assessments to determine the person’s level of suicide risk.  If a person is deemed “low risk” they are usually discharged the same day.  If the person is not deemed “low risk”, they may be admitted to an inpatient unit for further assessment and treatment. The length of stay at an inpatient setting depends on symptom severity, response to treatment, and suicide risk.

http://www.cdc.gov/violenceprevention/suicide/datasources.html

http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6013a1.htm

Simon, Rutter, Peterson…Ludman. 2013. Does Response on the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death? Psychiatric Services.