Suicide is a huge issue for people dealing with mental illness. While it doesn’t only affect people with mental illness, that’s the focus of this page. It’s important that we talk about it—not just talk around it, but straight talk on suicide in all its messiness and complexity. The conversation needs to address a range of different experiences related to suicide as well as the need for more effective mental illness treatment to mitigate risk. It’s important to hear the voices of those of us who have tried to take our own lives.
Based on 2018 figures, suicide is the 10th leading cause of death in the US, with men dying 3.56 times as often as women due to higher lethality methods. This is a massive problem, but it tends to be buried away under a little bit of shame and a whole lot of stigma.
So let’s talk about it.
Straight Talk On Suicide – Overview
Suicide: The Basics
“Suicidal ideation” (abbreviated SI) is the psychiatric term for suicidal thinking. It’s not an illness in and of itself, but it can be a symptom of major depressive disorder, bipolar disorder, borderline personality disorder, and various others. Not everyone who experiences thoughts of suicide has a mental illness, although many do.
Just as people have unique experiences of mental illness, there are unique experiences of suicidal thinking. The more you get to know your own pattern of illness and SI, the better the position you’re in to detect the warning signs early and take action to keep yourself safe.
Active & Passive Suicidal Ideation
Passive SI is along the lines of “I wish I was dead” or “I’d be better off dead,” but it doesn’t take that next step to thinking about actually doing something to make dying happen.
Active SI involves thoughts of actually doing something to end your life. The intent, plan specificity, and means availability can be variable. The higher those are, the more likely it is that the safest place to be is in hospital.
SI can also be described in terms of how it comes and goes. It may be “fleeting” if the thoughts sometimes come into your head but don’t stick around for very long. Some people experience chronic SI, with acute flare-ups in response to stressors.
Risk & Protective Factors
There are usually multiple factors that contribute to suicidality, including both predisposing factors (like mental illness) and situational factors. While it’s impossible to accurately pinpoint someone’s level of risk, the more risk factors they have, the greater the degree of concern.
Some of the major risk factors are:
- Mental illness (mood disorders in particular)
- Substance misuse (alcohol and other substances can disinhibit you, making you more likely to act)
- A previous suicide attempt
- Family history of suicide
- Significant life stressors
- Adverse childhood experiences (ACEs)
- Access to lethal means
- Suicide contagion (exposure to graphic or sensationalized talk of suicide)
Helping to balance out the risk factors are protective factors, including:
- family, social and professional supports (ideally some of each)
- spiritual or philosophical beliefs that act as a deterrent
- a sense of responsibility towards others (such as pets)
Identifying your protective factors while not in crisis can help give you a sense of what to lean into when things get hard. The most effective way to approach prevention is to not only try to reduce risk factors, but also improve protective factors.
Males die by suicide almost four times more often than females do. At least in part, this is because they tend to use more lethal methods like firearms, but cultural expectations to “man up” likely play a role as well. This gender imbalance is seen in all countries, although the exact proportion varies. Worldwide, men die about twice as often by suicide as women.
In the U.S., suicide is the 2nd leading cause of death among people aged 15-34, the 4th among 35-44 year-olds, and the 5th among age 45-54 year-olds. In older age groups, natural causes start to overtake suicide as the leading causes of death, but that doesn’t mean that suicide stops. The highest suicide rate for females is in the 45-64 age bracket (10.2 per 100,000), and for males, it’s the 75+ age bracket, at 39.9 per 100,000.
For people around us, suicide may seem like it comes out of nowhere, there are often warning signs. The acronym IS PATH WARM identifies red flags, especially when they represent deviations from that person’s norm. If you’re experiencing thoughts of suicide yourself and can check off a lot of these indicators, that’s a sign that it’s high time for intervention.
- Substance abuse
- Mood changes
Suicide Crisis Resources
This is a selection of some of the suicide prevention resources available in some of the major English-speaking countries. While I do periodically check that it’s up to date, I can’t guarantee that the contact details are always current.
Most crisis lines are run by non-profit agencies, and the people answering the phones are volunteers trained in supportive, non-judgmental listening. They will try to avoid calling emergency responders, but they’ll do so if there is an imminent risk of harm. In an interview with Buzzfeed, the associate director of the National Suicide Prevention Lifeline said that confidentiality is breached due to safety concerns for less than 3% of calls.
Crisis Resources by Country
Peer support services:
- Connections: peer support for suicide attempt survivors and people experiencing thoughts of suicide
- MH Crisis Angels: a Twitter-based peer support service – DM them for support
While contact info for crisis resources in these apps is country-specific, they still have content that’s useful for anyone wherever they are. Some have safety planning templates, which are noted below.
- A Friend Asks (US)
- Be Safe (Canada): includes a safety plan
- BeyondNow (Australia)
- Calm: Be Safe (Australia): includes a safety plan template, but with limited guidance
- My3 (US)
- Prevent Suicide (Northeast Scotland): includes a safety plan
- ReliefLink (US)
- Re–minder (Australia): includes a safety plan
- Safety Plan: from Zero Suicide (US)
- Stay Alive
- Suicide safety plan (UK)
- Suicide? Help! (UK)
- The Lifeline (Canada)
- Virtual Hope Box (iTunes | Google Play): from the US Department of Defense
In times of crisis, most people aren’t thinking very clearly. Putting together a safety plan ahead of time allows you to consider what the warning signs are that a crisis is building and identify interventions for the early, middle, and most intense stages of the crisis.
These sites have safety planning tools:
- Beyond Blue: web version and also on the BeyondNow app
- Consortium for Organizational Mental Health
- Suicide Prevention Resource Center
There are two free resources available from the MH@H Download Centre. They’re similar, but the Safety Plan is more geared toward chronic mental illness, while Feeling Suicidal? is geared more towards acute stressors.
- Coping with Suicidal Thoughts
- Military OneSource – Suicide (US military)
- Navigating a Mental Health Crisis: from the National Alliance on Mental Illness (NAMI)
Straight Talk on What’s Missing
A lot of suicide prevention campaigns focus on awareness, including being aware of crisis lines. Crisis lines/texts/chats are definitely a great resource when you need someone to talk to who will provide supportive listening, but that’s not the whole picture. When the underlying problem is mental illness, all the crisis lines in the world aren’t going to address the illness that’s causing the suicidal thoughts.
So absolutely, reach out to a crisis line to talk, but even more importantly, reach out to a mental health professional to help you manage your illness. Whether that starts with an appointment with your GP, finding a therapist, or making a trip to the emergency department, getting the illness better under control will ultimately be the most effective way of dealing with suicidality.
The sad reality, though, is that there is a very real risk of reaching out and not being taken seriously, or being told that you’re either not suicidal “enough” or “too” suicidal to be helped. Or perhaps there’s a year-long waitlist for appropriate treatment. Reaching out only works if the people and the system you’re reaching for don’t suck.
Besides the systems issues, the currently available treatments for mental illness don’t work for 100% of people, 100% of the time—not even close. Suicide can never be 100% preventable until that happens. In the meantime, though, we have to do the best we can with what we’ve got, as difficult as that may be.
Suicide and Stigma
Sadly, there’s a lot of stigma around suicide. This has been around for centuries, and the Catholic Church was an early driving force. These views made their way into English common law, which made suicide illegal. To this day, there are countries where it remains illegal, bizarre as that may seem.
While early stigma was primarily related to sinfulness, modern suicide stigma has different areas of focus. This post on suicide stigma looks at research identifying the most common stigmatized attitudes about someone who suicides:
- punishing others
Language matters when it comes to mental illness, but words are a reflection of attitudes, and changing attitudes is what will make a lasting difference, not trying to control people’s words.
Some advocates argue that certain language is stigmatizing, although what’s on the say vs. don’t say list varies depending on the source. “Commit suicide” is criticized for implying that suicide is a crime; however, that doesn’t mean that anyone other than those advocates has made that connection. Criminality is not among the common stigmatized beliefs about suicide, and creating that link for people isn’t likely to budge persistent beliefs about suicide being selfish.
These posts explore the issue of language and whether it’s a useful target for reducing suicide-related stigma:
- How picky should we be about suicide-related language?
- Is “committed suicide” worth making an issue out of?
How the media reports on suicides matters. Suicide contagion is a well-recognized phenomenon that involves an uptick in suicide rates that can occur following public suicides when there’s been inappropriate reporting. Carefully following suicide reporting guidelines can decrease the risk of this.
Suicide Reporting Do’s
- include local crisis line information and other community resources
- include warning signs and information about what to do
- report on suicide as a public health issue and look for links to broader social issues
- get information from suicide prevention experts
- word headlines carefully – avoid using the word “suicide” or sensationalizing
- be particularly careful when reporting celebrity suicides
- avoid printing photos of the deceased, or use only print a small, non-prominent image
Suicide Reporting Don’ts
- use prominent placement (e.g. front page) or undue repetition
- use photos of the location/method of death or family/friends grieving
- describe a suicide as inexplicable or without warning
- characterize suicide as “successful” or “unsuccessful”/”failed”
- report specific details of the method
- speculate about or offer simplistic causes for the suicide
- normalize or romanticize suicide or present it as the solution to problems
- use melodrama, hyperboles like “suicide epidemic” or labelling locations as suicide “hot spots”
- publish suicide notes
These sites have more info:
- Mindframe Guidelines (Australian)
- Mindset: Reporting on Mental Health (Canadian)
- Preventing Suicide: A Resource for Media Professionals from the World Health Organization
- ReportingOnSuicide.org reporting guidelines
- Resources for journalists from the AFSP
Straight Talk on Suicide
There are a couple of things I would like to make very clear:
1) Suicide is not selfish — not even a little bit.
2) Guilt isn’t effective as a suicide prevention strategy – it doesn’t work to try to guilt-trip someone out of suicide.
Yes, suicide hurts those left behind, but that’s not what the word selfish means. Here’s Google’s definition: “(of a person, action, or motive) lacking consideration for others; concerned chiefly with one’s own personal profit or pleasure.” There’s neither profit nor pleasure in suicide, so let’s put that nonsense to bed right now.
I’d also like to call bullshit on some of the quotes floating around online about suicide. The correct attributions are unclear.
- “Suicide doesn’t end the pain. It just passes it on to someone else.” – As previously mentioned, trying to guilt trip people out of suicide doesn’t help them; it only makes the person pulling that nonsense an asshole.
- “Suicide is a permanent solution to a temporary problem.” – Chronic mental illness is a permanent problem, and it’s not useful to belittle it this way.
- “Suicide doesn’t end the chances of life getting worse, it eliminates the possibility of it ever getting any better.” – Yes, as a matter of fact, it does end the chances of life getting worse, so it’s really not a helpful way of presenting the message that there is a possibility of things getting better.
You can read about my own experiences in this post that gets up close and personal. Suicide is tough to talk about, but it’s absolutely essential that we do so.
Barriers to Help-Seeking
Treatment needs to be available, but it also needs to be accessible. There can be multiple barriers to help-seeking for people experiencing suicidal ideation, including stigma, fear of becoming a burden, or fear of being hospitalized (or dismissed by the ER).
In the end, though, it comes down to a balance of risks and benefits. The potential risk of not seeking help is dying. There’s nowhere lower to go with seeking help.
In the book Suicidal: Why We Kill Ourselves, Jesse Bering described a process called cognitive deconstruction, which is a mental narrowing of focus and time frame of reference that can occur in the lead-up to suicide. The future and consequences cease to exist; there’s just now. That now is a very concrete, non-abstract place, with everything tuned out except the one thing that’s focused on.
This sounds very much like my own experience leading up to attempting suicide. Recognizing that process is occurring can be an important sign that it’s time to reach out for help. You can read more in this post on cognitive deconstruction. It helps an illogical thought process to make a lot more sense.
Is Suicide a Choice?
If suicide is a choice, does that mean that it’s blameworthy, selfish, and all that other stigmatized crap? I suspect one of the reasons that some suicide prevention advocates argue that it’s not a choice is to try to avoid leaving that door open.
However, the reality is a lot more nuanced than that. Suicidal ideation as a symptom of mental illness is not a choice. However, suicide itself is an intentional action, not a passive state of being or an involuntary act.
Being a choice doesn’t mean that there are better choices available, or that the menu of options include what you’d like it to. Mental illness severely limits the options that are on the menu. On a two-option menu of dying or living in pain, living could sometimes appear to be a worse choice than death.
To deny the element of choice loses sight of the fact that we need to make sure better options are available to people. Suicide having an element of choice is actually a good thing, because it means that it’s possible to introduce better choices.
LGBTQ+ Youth Elevated Risk
Because of factors like bullying, microaggressions, and lack of social support (including family support), LGBTQ+ youth have significantly elevated rates of suicide. LGB youth attempt suicide five times more often than heterosexual youth. Suicidal ideation is even higher among trans youth than LGB youth, and higher still for trans youth who want puberty-blocking or other hormonal treatment but are unable to access it.
What’s important to keep in mind here is that there’s nothing inherent in being LGBTQ+ that makes people suicidal. This is entirely society’s fault for not supporting these youth.
Suicidality vs. Self-Harm (Non-Suicidal Self-Injury/NSSI)
Non-suicidal self-injury (NSSI) is a more specific term than self-harm that makes it clear that the self-injury is not intended to result in ending one’s life. The post Harm Reduction for Self-Harm has more info on managing NSSI as safely as possible.
Self-harm and attempting suicide aren’t the same thing. They both cause harm, but the intent is quite different. There are a variety of reasons why people may self-harm, including to release emotional pain or to create physical pain to cut through emotional numbness. I briefly self-harmed early in the course of my illness, and it was a way of managing suicidal ideation to prevent myself from acting on it.
People can experience suicidal ideation and at the same time engage in NSSI, so it’s important not to overlook one and focus solely on the other. Unfortunately, there is a risk that people, including health care providers, may minimize suicidality when there’s also NSSI, so you may need to advocate hard for yourself.
Suicide Attempt Survivors
Let’s also talk about suicide attempt survivors. It doesn’t get talked about much, but there are quite a few of us out there. I’m a multiple attempt survivor myself. It’s been about 8 years since my last attempt, and while my depression is treatment-resistant, the suicidal ideation is pretty well controlled with meds. I’ve never been an impulsive attempter, and when SI does flare up sometimes, I know from past experience that I’m able to make it through prolonged periods of constant suicidality, so I’m able to put it in context that a week or two of suicidality isn’t high risk for me. Looking to your past to understand your patterns can help with making more effective, safe decisions moving forward.
Everyone’s experience is different. Some people regret the attempt afterwards, while others, such as myself, regret not dying. There’s no one right way to feel, and by sharing our experiences collectively, we can help others recognize that they’re not alone in their experience.
As an attempt survivor, I had a strong reaction to a chapter in Jesse Bering’s book Suicidal that included excerpts from the journal of a teen who had ended her life. It was done with her parents’ permission, and I suppose there isn’t really an entitlement to privacy when you’re dead, but it’s certainly not something I would want to happen. You can read more in this post on privacy and completed suicide.
Symbols can be a powerful way of representing one’s relationship with suicide. The awareness ribbon can speak to anyone, but the other two are more personal. A semicolon tattoo is a common choice among those who have survived an attempt; it represents where a sentence could have ended, but the writer kept on going instead. The mythical phoenix rising from the ashes is a powerful metaphor for dying and rising again. I have a phoenix tattoo to represent surviving my last attempt.
Resources for attempt survivors:
- A Journey Toward Health & Hope: Your Handbook for Recovery After a Suicide Attempt: from the Substance Abuse and Mental Health Services Administration (SAMHSA)
- Help & Hope: For Survivors of Suicide Loss: from STOP Suicide Northeast Indiana
- Toolkit for People Who Have Been Impacted by a Suicide Attempt from the Mental Health Commission of Canada
- With Help Comes Hope: from the National Suicide Prevention Lifeline
While “suicide attempt survivors” refers to those who have attempted and lived, the term “suicide survivors” is used to refer to people who have lost a loved one to suicide.
- Alliance of Hope for Suicide Loss Survivors: a charity created by survivors for survivors
- Children, Teens, and Suicide Loss: booklet from the American Foundation for Suicide Prevention
- Friends for Survival: peer support
- Heartbeat: Survivors After Suicide: support groups
- Hope and Healing: A Practical Guide for Survivors of Suicide from the Centre for Applied Research in Mental Health and Addiction (CARMHA)
- SOS: A Handbook for Survivors of Suicide: from the American Association of Suicidology
- TAPS Suicide Loss Supports: resources for survivors of US military suicide loss
If you post on social media about being suicidal, there’s a possibility that someone might report you to the social platform. At that point, they’ll probably send you a list of crisis line contacts, but more importantly, they may temporarily disable your account. The intent may be good, but it can end up cutting people off from an important support system.
Part of your safety planning process might involve considering how to reach out effectively on social media in times of need. Broadcasting messages to thousands of followers may end up worrying and/or triggering large numbers of other people without actually doing anything to help you get more effective support. A more focused plan for connecting with key supports may help you get the help you need without risking having your social account suspended.
The following posts have more on this topic:
- Suicidal Posts on Social Media: What Should Platforms Do?
- What if a stranger tells you they’re suicidal?
The Mental Health Commission of Canada has information on how to have safer conversations about suicide on social media.
Advocacy Campaigns & Resources
If you’re interested in getting involved in larger-scale advocacy work, these sites have resources that may be of interest to you:
- Active Minds Means Reduction Campaign guide for students
- American Foundation for Suicide Prevention (AFSP):
- Location and Understanding Data for Suicide Prevention: online course from the Suicide Prevention Resource Center
- Suicide Prevention: Guidelines for Public Awareness and Education Activities from the Province of Manitoba
- Suicide Prevention Resource Center: Virtual Learning Labs for suicide prevention campaigns
Resources for systems-level change
- Preventing Suicide: A Technical Package of Policy, Programs, and Practices from the US CDC
- The Surgeon General’s Call to Action to Implement the National Strategy for Suicide Prevention
Suicide Prevention Resources for Professionals
- Ask Suicide-Screening Questions (ASQ) Toolkit from the National Institute of Mental Health
- Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professional from the Suicide Prevention Resource Center
- CASE Approach (Chronological Assessment of Suicide Events): developed by Dr. Shawn Christopher Shea, who is the author of the excellent book Psychiatric Interviewing: The Art of Understanding
- Columbia-Suicide Severity Rating Scale (C-SSRS)
- Suicide Risk Assessment Toolkit and Suicide Risk Assessment Guide from the Canadian Patient Safety Institute
- Working with the Client Who Is Suicidal: A Tool for Adult Mental Health and Addiction Services: from the Centre for Applied Research in Mental Health and Addiction (CARMHA)
- Working with the Suicidal Patient: A Guide for Health Care Professionals: this 4-page guide is also from CARMHA
- American Psychiatric Association webinars:
- Canadian Patient Safety Institute: Mental Health Care: Preventing Suicide and Self-Harm
- MD Briefcase: Suicide: Facing the Difficult Topic Together – Empowering Physicians, Instilling Hope in Patients
- Mental Health Commission of Canada learning modules: Suicide: Facing the Difficult Topic Together – Empowering Physicians and nurses, Instilling Hope in Patients
- SMI Advisor: an APA-run site focused on serious mental illness
- Creating and Sustaining High-Quality Crisis Services: A Systemic Approach
- Rare but Real Risk of Firearms and Treatment of Individuals with Serious Mental Illness: assessment related to suicide risk and firearms in the US
- Suicide Prevention Resource Center webinars
- Suicide Bereavement Clinician Training: from the American Foundation for Suicide Prevention
- VA National Center for PTSD:
- Zero Suicide:
- Suicide Prevention and Recovery Guide: A Resource for Mental Health Professionals from SANE Australia
- Zero Suicide Toolkit for health care systems transformation
Learn More About Suicide
These sites have courses/learning resources about suicide geared towards a broad audience:
- ASK About Suicide video series
- FutureLearn: Understanding Suicide and Suicide Prevention Strategies in a Global Context
- Suicide Prevention Resource Center training hub
- Zero Suicide Alliance: Step Up, Gateway, and Suicide Awareness trainings
These sites have lots of suicide prevention info:
- American Foundation for Suicide Prevention
- Centers for Disease Control and Prevention
- National Institute of Mental Health
- R U OK? (Australia)
- Suicide Awareness Voices of Education
- Suicide Prevention Resource Center
- Zero Suicide Alliance
Books About Suicide
I’ve reviewed these books on Mental Health @ Home.
- Hello, Cruel World: 101 Alternative to Suicide for Teens, Freaks & Other Outlaws by Kate Bornstein
- Hello I Want to Die Please Fix Me by Anna Mehler Paperny
- Reasons to Stay Alive by Matt Haig
- The Suicidal Thoughts Workbook by Kathryn Hope Gordon
- Suicidal: Why We Kill Ourselves by Jesse Bering