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SUICIDE PREVENTION:
ASSESSMENT AND
TREATMENT
Part I
DANA BARTLETT, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and
author. His clinical experience includes 16 years
of ICU and ER experience and over 20 years of
as a poison control center information specialist.
Dana has published numerous CE and journal
articles, written NCLEX material, written
textbook chapters, and done editing and
reviewing for publishers such as Elsevire,
Lippincott, and Thieme. He has written widely
on the subject of toxicology and was recently named a contributing editor, toxicology
section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison
Control Center and is actively involved in lecturing and mentoring nurses, emergency
medical residents and pharmacy students.
Abstract
Suicide is a leading cause of death in the United States. The literature on
suicidology and large-scale studies conducted over the years suggest that
there continues to be high rates of suicide among youth, men, and
individuals with a mental illness as well as members of ethnic and social
groups. The prevalence, risk and protective factors for suicidal thought and
actions are discussed in this course. A general approach to highlight key
studies and theories on suicidal risk factors and behaviors including an
emphasis on modifiable risk and prevention is offered. Specifically, caring for
family members and clinician self-care following a patient suicide is
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highlighted in this 2-part series.
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Health clinicians need to know how to work with a patient in suicidal crisis.
This includes knowing the guidelines on suicide assessment, treatment and
management, including ethical and legal considerations. Additionally,
clinicians should be aware of the prevalence of suicide, issues related to atrisk or vulnerable populations, and protective factors among various ethnic
and racial groups to better evaluate patients for suicide risk. Clinicians that
are aware of suicide myths, and common warning signs of a patient at risk
for suicide, are better able to assess patients, develop a therapeutic alliance
with patients, recommend various treatment approaches; and, an informed
clinician is better able to incorporate professional recommendations of selfcare while dealing with a suicidal patient.
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Course Purpose
To provide health clinicians with knowledge of the guidelines on suicide
prevention, including assessment and treatment of the patients and families,
for individuals of all age groups in varied civilian and military roles, as well
as observing professional guidelines for clinicians to care for themselves
while caring for a suicidal patient or in the event of a patient suicide.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –
all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. The CDC estimates _____ attempted suicides occur per every
suicide death.
a.
b.
c.
d.
4
7
11
18
2. Suicide is the _____ leading cause of death among teenagers.
a.
b.
c.
d.
number one
second
third
fourth
3. Which of the following is defined as “nonlethal intentional selfinjurious behavior”?
a.
b.
c.
d.
Contagion
Parasuicide
Suicidal ideation
Cluster
4. Which of the following is defined as “a phenomenon whereby
susceptible persons are influenced toward suicidal behavior
through knowledge of another person’s suicidal acts”?
a.
b.
c.
d.
Contagion
Parasuicide
Suicidal ideation
Cluster
5. The increased suicide rate in the United States is especially
pronounced in
a.
b.
c.
d.
teenagers.
middle aged adults.
older adults.
middle aged women.
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Introduction
One of the most challenging and prevalent issues clinicians can face is a
patient’s suicidal crisis. Suicide is defined as self-inflicted death with
evidence (either explicit or implicit) that the person intended to die.
Although many patients experience major depressive episodes, training on
how to manage suicidality is often not a component of training curriculums.
Many recommendations are impractical to manage an emerging crisis.
Working with a patient in suicidal crisis can be difficult and evoke strong
feelings in the clinician. This course will provide discussion and highlight
guidelines on suicide assessment, treatment and management.
Overview Of Suicide Prevention
In a 2014 American Psychology Association (APA) Monitor publication,
Nadine Kaslow, APA President, sent an alarming message to clinicians to
continue to focus on developing a public health perspective to reduce
suicide. She stated that such an agenda must address diverse populations
and span the continuum of suicidal behavior. Some of Kaslow’s suggestions
included: 1) standardizing and providing training to psychologists and
trainees on suicide assessment and treatment, 2) training community
members as gatekeepers for identifying and referring those at risk, and
3) creating, assessing and disseminating programs that have a broad
impact.1 Such services are most assuredly needed.
The prevalence of suicide needs to be understood by clinicians. The National
Institute of Mental Health has termed suicide as a major public health
problem.2 According to the Centers for Disease Control and Prevention
(CDC) statistics, suicide was the tenth leading cause of mortality in the
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United States, accounting for 41,149 deaths in 2013.3 Many people attempt
suicide, but do not actually complete the attempt. These statistics estimate
11 attempted suicides occur for every suicide death.3 Most people who die
by suicide have risk factors of depression and other significant mental health
issues, a substance use disorder, or a combination of risk factors.
In addition to the numbers quoted above, suicide is a growing concern for
clinicians treating adolescents. A CDC study found that 16% of adolescents
in grades 9-12 had seriously considered suicide and 8% attempted to do so.4
As these statistics suggest, health clinicians may often see suicidal ideation
and suicidal behaviors among their patients.
The identification of suicide risk remains among the most important,
complex, and difficult task performed by clinicians. Research has confirmed
that most mental health professionals have experienced at least one patient
suicide.6 Patient suicide can have profound personal and professional effects,
including increased levels of anxiety and stress, isolation and withdrawal,5
and damage to the therapists’ personal relationships. There may also be
evidence of depression, a protracted grieving process, symptoms of
posttraumatic stress or vicarious traumatization.
Therapists working with suicidal patients have many responsibilities. These
include developing a skill set and protocols for: 1) Treating clients who may
be at risk for suicide, 2) Accurately assessing suicidal risk, 3) Responding to
a client’s suicide attempt, and 4) Implementing self-care activities. It is
important for clinicians to be knowledgeable when asking patients about
suicidal ideation and behavior. It may be challenging for clinicians to balance
their own comfort level with the need to obtain accurate and clear
information.
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Terminology
Prior to looking at assessment and treatment of suicidal behavior, the
following terms should be reviewed.

Suicide: Self-inflicted death with evidence that the person intended to
die.

Suicide attempt: Self-injurious behavior with a nonfatal outcome and
accompanied by evidence that the person intended to die.

Parasuicide: Any nonlethal intentional self-injurious behavior that is
intended to express suicidal feelings but not to cause harm. This is
often called a suicide gesture.

Suicidal ideation: Thoughts of suicide. They can vary in seriousness
depending on how specific a suicide plan is, and the degree of intent.

Suicidal intent: The seriousness or intensity of a person’s wish to
terminate his or her life.

Lethality of suicidal behavior: Objective danger to life associated with
a suicidal method; lethality may not always coincide with an
individual’s expectation of what is medically dangerous.

Contagion: A phenomenon whereby susceptible persons are influenced
towards suicidal behavior through knowledge of another person’s
suicidal acts. There is evidence that suggests suicide is socially
contagious, but there is also doubt that this is true and a lack of clarity
regarding the definition of contagion as it pertains to suicide.

Cluster: A suicide cluster is defined as a higher number of suicides
occurring in a space and/or time than what is normally.

Resilience: Capacities within a person that promote positive outcomes,
such as mental health and wellbeing, and provides protection from
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factors that might otherwise place that person at risk for adverse
health outcomes and suicide.
Suicide Prevalence
Selected suicide data from the CDC and other noted sources are summarized
below.3

In 2013, suicide was the 10th leading cause of death for Americans.

From 1999 to 2014 the age-adjusted suicide rate in the United States
increased 24%.

Suicide death rates vary considerably among demographic variables
including age, sex, race/ethnicity, and geographic region/state. Other
variables that may also affect suicide rates are socioeconomic status,
employment, occupation, sexual orientation, and gender identity.

Whites, Native Americans, and Alaska natives are particularly at risk
for suicide.

Men commit suicide at four times the rate of women, but women are
more likely to have suicidal thoughts. Men typically commit suicide by
using a firearm, women by self-poisoning.

A significant number of people who commit suicide will have a positive
test for the presence of alcohol, anti-depressants, or opioid analgesics.

In 2013, 494,169 people were treated in emergency rooms for selfinflicted injuries.

Sexual and gender minorities are at a higher risk for suicide than
heterosexuals.

The increased suicide rate in the United States is especially
pronounced in older adults, and older adults have more completed
suicides.
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It is important to note that these prevalence statistics are estimates, and it
is difficult to know exactly how common suicidal behavior is in the general
population and in subgroups. Suicides are often underreported, in part
because it may be difficult to determine intent. Existing data collection
instruments may also fail to include questions that would determine the
prevalence of suicidal behaviors in specific groups. For example, because
death certificates do not indicate sexual orientation and gender identity,
rates of deaths by suicide in lesbian, gay, bisexual, and transgender (LGBT)
populations are unknown and many of the research studies provide
estimates only.
Theories Of Suicidal Behavior
Many of the current theories of suicidal behavior are based on a stressdiathesis model. In this model, suicidal behavior involves an interaction of
trait-dependent/constant risk factors (diatheses) and a state-dependent
trigger or stressor that is only present during certain periods of time. When
both are in place the likelihood of suicidal behavior is increased; if only one
is present the risk is less.
Cognitive Stress Diathesis Model
The cognitive stress diathesis model of suicide evaluates suicidality as a
result of a combination of neuropsychological deficits in areas of memory,
attention or problem solving along with stressors that result in perceptions
of hopelessness, immovability, or esteem issues. The three primary
components of this model are discussed below.5
Oversensitivity to Signals of Defeat:
Researchers used the emotional Stroop task (measuring response time of
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the participants to name colors of negative emotional words), and isolated
attentional biases/perceptual pop-outs in association with suicidal behavior;
hypersensitivity to stimuli signaling “loser” status increases the risk that the
defeat response will be triggered.
Perceived No Escape:
Researchers theorized that problems with autobiographical memory limit the
ability to problem-solve and when an individual is faced with stress, he or
she may feel as if there is no escape from problems or life events. An
individual may also think in an overly general way that prevents focusing on
the details that could help problem solving.
Perceived No Rescue:
Suicidal behavior may be associated with limited fluency, and an inability to
come up with positive events that might happen in the future. Thus, people
may feel as if there is no rescue from the current life situation. They may
also be unable to generate positive future events, causing significant levels
of hopelessness, a core clinical predictor of suicidal behavior.
Clinical Stress Diathesis Models
The McGirr and Turecki model is based on the idea that psychopathology is a
necessary, but not sufficient, factor for suicide. The authors noted that
people who attempt or commit suicide might have a predisposition to do so
because of aggressive and impulsive personality traits. Individuals with
suicidality engage in behaviors without consideration of consequences,
behaviors that are risky or inappropriate to the situation, and are
accompanied by undesirable outcomes.
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Neurobiological Stress Diathesis Model
Another example of a stress diathesis model of suicide uses neurobiological
data. Some research included the use of PET studies to compare young men
with a history of attempted suicide to young men with no suicide history.
Groups involved in studies were shown pictures of angry, happy, and neutral
faces. The young men with a suicide history demonstrated significant
differences in brain activity. Those attempting suicide were distinguished
from non-suicidal patients by their responses to angry and happy faces,
suggesting increased sensitivity to others’ disapproval, higher propensity to
act on negative emotions, and reduced attention to mildly positive stimuli.
The authors concluded that these patterns of neural activity and cognitive
processes might represent vulnerability markers of suicidal behavior in men
with a history of depression, which was supported by later studies.
Interpersonal Model of Suicidal Behavior
The interpersonal theory of suicidal behavior holds that there are two factors
that must be present for a person to commit suicide:6 1) Perceived
burdensomeness, or the feeling that one is a liability, and 2) Thwarted
belongingness or a feeling that there are no meaningful social connections.
These feelings along with hopelessness, increased pain tolerance, and
reduced fear of death, are the proximal causes of dangerous suicidal
behavior. For example, the capability for suicidal behavior emerges in
response to repeated exposure to physically painful and/or fear-inducing
experiences. Such repeated exposure results in habituation and ultimately a
higher tolerance for pain and a sense of fearlessness about death. Some
researchers have suggested that clinicians should be cognizant of their
patients’ levels of belongingness, burdensomeness, and acquired capability
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(especially previous suicide attempts), in assessing suicide risk and in
targeting therapeutic interventions.
Research in Suicidology
Suicidology is the scientific study of
suicide. Suicide research is aimed at
understanding and preventing suicide.
The primary fields involved in suicide
research are psychology and
sociology. The following approaches
help to shed light on the research.

Psychological research focuses on
the psychological states
experienced by the person attempting or completing suicide. This can
include the cognitive, behavioral or emotional components and states.

Psychodynamic researchers focus on the role of anxiety and inner
conflicts, postulating that suicide is how people express anger and
hostility, generally as a way of turning these emotions inward. Rage,
hopelessness, despair, and guilt are important affective states leading to
suicide. The meanings of suicide can be usefully organized around the
conscious and unconscious meanings given to death by the suicidal
patient, for example, death as retaliatory abandonment, death as
revenge, death as self-punishment or atonement.

Biological, biochemical and constitutional research looks at how genetics,
neurotransmitters, hormones, and biochemistry influence suicide.
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Biological suicide research has developed as an offshoot of biological
depression research. Many of the studies are conducted after a person
has committed suicide or are twin studies.

Sociocultural research assesses the degree to which someone's
surroundings exert a positive or negative influence; whether an
individual's family, community and country are supportive or stressful.

Psychiatric and mental illness researchers look at the connections
between mental illness and suicide.

Epidemiological and demographic research identifies populations most at
risk for suicide. Some of the demographic factors studied are gender,
race, sexual orientation, health issues, seasonal factors, and trends.

Prevention, intervention and post-intervention research looks at how to
prevent suicide from occurring (usually in specific at-risk groups), how to
intervene in cases of active suicidality, and how to respond following
completed suicide (alleviating the effects in family members and
community).
Key Research Findings/Risk Factors
Case Vignette I
Emma is a 24-year-old survivor of multiple traumas and recently diagnosed with
a dissociative disorder. She is overwhelmed by the diagnosis and the need to
start to work on her past trauma. She expresses that “this is too hard,” and “I
don’t want to live like this anymore.” Her therapist expresses an understanding
of the difficulty of the diagnosis and task and assumes that her expression of
suicidal ideation is a communication of this difficulty. Her therapist is upset
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when she receives a call indicating that Emma has been admitted to a hospital
following a serious suicide attempt. Fortunately, Emma will be okay.
Case Vignette II
Kevin is a 35-year-old man who has struggled with depression and alcoholism
for many years. While he is attending therapy groups, his level of commitment to
them appears minimal. He does not appear actively suicidal, but his group
therapist is alarmed by disclosures in the group that indicate Kevin does not feel
he has a reason to live. The therapist does an assessment, which indicates that
Kevin’s level of suicidal ideation is high; he has a plan, and he fully intends to kill
himself. She can persuade Kevin to consider hospitalization and is hopeful that
the situation will resolve.
The situations discussed above are common in clinical practice. In
understanding why some clients consider and follow through with suicide
attempts, it is helpful to look at the research literature. The effectiveness of
clinicians in the prevention of suicide depends on understanding how and
why suicide occurs. Related factors or triggers for suicide attempt or
completion identified in the literature are reviewed below.7-17
Previous Suicide Attempts and Suicidal Ideation
The data from the United States and abroad has found a positive correlation
between suicide attempts and subsequent completed suicide, and suicidal
ideation is a risk factor for suicide attempts and completed suicide.
There are approximately 10-40 suicide attempts for every completed suicide,
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and adolescents make far more suicide attempts (100 to 200) than complete
the act.
Age and Gender
Older adults are more likely to complete suicide than younger adults.
Women have more suicidal ideation and make more suicide attempts than
men, but more men than women complete suicide.
Family History
Family history and by implications genetics can be a risk factor for suicidal
behavior and suicide. The heritability of suicide has been estimated to be
30-50%, and a national registry study showed that risk of suicide was
significantly increased if a sibling had committed suicide.
Another interesting approach is the social model thesis. This model says that
exposure to completed and attempted suicide in the family can increase
suicide risk among other family members by providing a social model of selfharm behavior. The researchers suggested containment of information
regarding suicidal behaviors in prevention of suicidality.
Medical Conditions
Patients with serious medical conditions may be at increased risk for suicide.
These include but are not limited to chronic pain, cancers, HIV/AIDS, lupus,
headache, traumatic brain injury, fibromyalgia, and diseases of the central
nervous system such as Alzheimer’s disease, epilepsy, Huntington’s disease,
and multiple sclerosis.
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Environmental Stressors
Personal stress is a significant risk factor for suicidal behavior and suicide.
Acute and chronic stressors that increase the risk of suicidal behavior and
suicide include bullying, intimate partner violence, financial stress, and death
of a spouse or relative.
Access to Lethal Methods/Impulsivity
Many suicide attempts are impulsive or unplanned and occur during an acute
period of ambivalence, and impulsivity and aggression have been shown to
be risk factors for suicide. Access to a lethal means of suicide such as
firearms or highly toxic pesticides are recognized as risk factors for suicide.
Biological Bases of Suicide
Researchers have studied the brains of people who have died by suicide,
looking for visible differences from brains of those who died by other causes.
Most frequently studied have been the serotonergic system, adrenergic
system, and the hypothalamic-pituitary axis (HPA), all of which influence
mood, thinking and stress response. A key challenge of neurobiological
studies is determining the abnormalities in genes, brain structures, or brain
function that differentiate depressed people who died by suicide from
depressed people who died by other causes.
Summary of risk factors







Previous suicide attempts
Family history of suicidal behavior
Medical conditions and chronic pain
Contagion (local epidemics of suicide)
Access to lethal methods
Isolation, a feeling of being cut off from other people
Previous suicide attempt(s)
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 Loss (relational, social, work or financial)
 Unwillingness to seek help due to stigma
Protective Factors For Suicide
Protective factors for suicide are characteristics or conditions that may help
to decrease a person’s suicide risk. It is important to note that these factors
have not been well studied, and that while they do not eliminate the
possibility of suicide, especially in someone with risk factors, these
protective factors may help reduce the risk. Protective factors for suicide
have been identified as:18,19,44

Effective mental health care

Connectedness to individuals, family, community, and social
institutions

Problem-solving skills

Contacts with caregivers
The most consistent protective factors found in suicide research are social
support and connectedness and hopefulness. Marital status is also linked
with suicide risk. Married individuals are less likely to commit suicide than
divorced or separated people, and divorce has been associated with an
increased risk of suicide. Among females, another protective factor appears
to be parenting, which provides a sense of purpose and reason for women to
not give up despite having depression or suicidal thoughts.
Some researchers have looked at protective factors against suicidal acts in
major depression. Researchers assessed inpatients with major depression,
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general psychopathology, suicide history, and hopelessness. Of the 84
patients, 45 had attempted suicide and 39 had not. The depressed patients
who had not attempted suicide expressed more feelings of responsibility
toward family, more fear of social disapproval, more moral objections to
suicide, greater survival and coping skills, and a greater fear of suicide than
the depressed patients who had attempted suicide.
Linehan, et al. developed the Linehan Reasons for Living Inventory (LRFL).
This is a 48-item self-reported assessment tool that reflects adaptive beliefs
and expectations that help people resist suicidal urges, and it may be used
to explore differences in the reasons for living with individuals who engage in
suicidal behavior and those who do not.21
The LRFL consists of six subscales and a total scale. The subscales include:
survival and coping beliefs (24 items), responsibility to family (7 items),
child-related concerns (3 items), fear of suicide (7 items), fear of social
disapproval (3 items), and moral objections (4 items). Examples from the
six subscales are provided below. Each item is rated on a 6-point scale
ranging from 1 (not at all important) to 6 (extremely important).
1. I care enough about myself to live.
2. It would hurt my family too much and I would not want them to suffer.
3. The effect on my children could be harmful.
4. I am a coward and do not have the guts to do it.
5. Other people would think I am weak and selfish.
6. I believe only God has the right to end a life.
Linehan, et al. classified respondents into four categories: 1) those never
considering suicide in any way, 2) those who considered suicide only briefly
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or non-seriously, 3) those who seriously considered suicide, or 4) those
having made a suicide attempt. They found that the respondents who had
never considered suicide had more self-reported reasons for living, and
better coping and survival skills.
Religion appears to play a protective role in suicide due to the strict
sanctions against suicide in most major religions, and religiosity has been
shown to be associated with reduced risk of suicidality.64 Christianity,
Hinduism, Islam, and Judaism all condemn suicide, although the strictness of
this condemnation varies. Research also confirms that more traditional or
orthodox religions tend to have lower suicide rates. Fostering a suicidal
person’s spiritual or religious faith may contribute to the effectiveness of
interventions.
An area of emerging research concerns the protective factor of high distress
tolerance. Simply put, distress tolerance concerns the accepting, finding
meaning for, and tolerating distress. Distress intolerance, on the other hand,
is a perceived inability to fully experience unpleasant, aversive or
uncomfortable emotions, and is accompanied by a desperate need to escape
the uncomfortable emotions. Distress tolerance skills support the ability to
accept, in a non-evaluative and nonjudgmental fashion, both oneself and the
current situation. Anestis, et al. studied 93 adult inpatients who were
receiving treatment for substance use disorders.22 Each patient completed a
structured interview assessing suicide potential. Results indicated that in atrisk populations, the capacity to tolerate aversive physiological and affective
arousal might reduce the risk of serious or lethal suicidal behavior.
Suicide And Mental Health Diagnoses
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Suicidal ideation or attempts are a clear indication that something is very
wrong in a person’s life, and most people who die by suicide have a mental
or emotional disorder. Suicide research often uses a method termed
psychological autopsy in which researchers conduct interviews with family
members and friends, who provide information on their understanding of the
likely factors that contributed to the person’s death. Most suicide events
occur in people who have a psychopathology such as bipolar disorder or
depression, and although the great majority of people who have a mental
disorder do not commit suicide, the results of several studies suggest that
the vast majority of those who committed suicide had a psychiatric diagnosis
at the time of death. In particular, people who have bipolar disorder,
borderline personality disorder, a substance use and addiction disorder,
eating disorders, major depression, post-traumatic stress disorder, psychotic
disorders, or schizophrenia have an increased risk of suicide behavior.23
Throughout history, mental illness has been associated with stigma and seen
as a sign of weakness or deficiency. There is also the sense that those
affected by mental illnesses may be dangerous or unpredictable. This sense
of stigma increases the risk of suicide by increasing secrecy and precipitating
shame and self-blame, all of which discourage affected individuals from
seeking treatment. This is especially true among certain ethnic and racial
groups. Prior to looking at the connections between suicide and specific
mental illnesses, it is helpful to briefly explore here the connections between
mental illness and stigma as a causal
factor of suicide.3,24-41,86-89
Mood Disorders and Suicide
Mood disorders, especially bipolar disorder
and depression, are significant risk factors
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for suicide. A key aspect of risk among people with mood disorders is the
presence of hopelessness, as indicated by negative attitudes, or pessimism,
about the future. Hopelessness theory, first proposed by Abramson,
Metalsky, and Alloy in 1989, postulated that people with depression tend to
make internal, stable, and global attributions to explain the causes of
negative events, and external, unstable, and specific attributions about
positive events. This attributional style results in the individual taking
personal blame for negative events in his or her life.
Hopeless can be measured using the Beck Hopelessness Scale. This is a 20item self-report inventory that measures negative and positive attitudes
about the future in terms of affective, cognitive, and motivational factors. An
example is that an affective statement would be “I look forward to the future
with enthusiasm.” A ‘yes’ would score 0, a ‘no’ would score 1, and of the
possible results of 0 - 20, a score of 0 – 3 indicates a minimal level of
hopelessness; 4 – 8 a mild level; 9 – 14 a moderate level; and, 15 – 20, a
severe level. The Beck Hopelessness Scale has been shown to have a strong
predictive value for suicide and suicide behavior.
Other risk factors for suicide among people with mood disorders include (but
are not limited to) previous suicide attempts, family history of
depression/suicidal behavior, lack of social support, impulsive or aggressive
behavior, severity of depression, a history of sexual abuse, and comorbid
states of anxiety, panic disorder, or substance use.
Substance Use/Alcohol Use Disorders and Suicide
As mentioned earlier, a significant number of people who commit suicide will
have a positive test for the presence of alcohol, antidepressants, or opioid
analgesics. Alcohol use disorder and substance use have been consistently
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identified as risk factors for, and strongly associated with suicide, suicide
ideation, suicidal behavior, and suicide.
Concurrent substance use and bipolar disorder or major depressive disorder
is very common and associated with greater functional, psychological and
social impairment, increased resistance to treatment, poorer prognosis, and
more severe depressive symptoms. Alcohol use disorder increases
aggression and impulsivity, another risk factor for suicide. Specific factors in
people who have concurrent depression and substance use disorder that can
increase the risk of suicide are age (older people are at greater risk),
dysfunctional attitudes, feelings of hopelessness, male gender, the age at
which the psychiatric illness began, and the severity of the psychiatric
illness. People who have an alcohol use disorder may be more vulnerable to
suicide if they are over 50 and are male, unemployed, living alone,
experience a major depressive episode, experience a stressful life event,
have poor social support, or have a substance use disorder or a serious
medical illness.
An emerging area of study involves the connection between addictive
disorders such as pathological gambling and suicidality. In pathological
gambling, multiple financial, occupational and relationship problems and
losses can occur, and people who are pathological gamblers have an
increased risk of suicide, suicidal ideation, and suicidal behavior. Thon et al.,
reviewed questionnaires that had been completed by 862 pathological
gamblers; the rate of attempted suicide in this group was 4-20% and
12-92% of the respondents had suicidal ideation.
Schizophrenia and Suicide
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Suicide is one of the most common causes of death in people who have
schizophrenia, and the risk of suicide in this population is significantly higher
than in the general population.
Accurate and reliable assessment for the risk of suicide in schizophrenic
patients has been reported to be very difficult, but research and clinical
experience suggest that there are psychological and social factors that
increase risk in this population. These factors include feelings of agitation,
depression, and hopelessness, insomnia, male gender, poor compliance with
treatment, previous suicide attempts, and social isolation. Protective factors
include delivery of and adherence to treatment, the use of antipsychotics
(particularly clozapine), antidepressants, and psychosocial treatments.
Suicide in schizophrenic patients is especially common in the first years after
onset of the disease, and if a patient has been recently diagnosed with
severe psychotic symptoms, social impairment, substance use disorder, and
many of the risk factors previously listed this increases the risk of suicide.
Anxiety Disorders and Suicide
Anxiety disorders, including panic disorder, agoraphobia, social phobia,
specific phobia, generalized anxiety disorder, and posttraumatic stress
disorder have been associated with suicide and suicidal ideation and
identified as predictors for suicide attempts and ideation. However, studies
have found that anxiety posed a statistically significant, yet weak, predictor
of suicide ideation, attempts, but not deaths. Researchers have also found
that findings do not translate into clinically practical information ... (and)
anxiety and its disorders, at least as these constructs have been studied to
date, are unlikely to serve as powerful actual or real-world indicators of risk
for suicidal thoughts and behaviors. Nepon, et al. pointed out that there are
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high levels of comorbidities in people who have anxiety disorders and these
comorbidities, not the anxiety, may explain the suicidal behavior in these
patients.
Sleep Disorders and Suicide
Insomnia and other sleep disorders are common in people who have a
psychiatric illness that predisposes them to suicide. Research of the link
between insomnia, sleep disorders, and suicide has often had methodological
problems (i.e., failure to account for presence of psychopathology as a
confounder, definitions and measurements of insomnia and sleep disorders)
that limited the findings. However, recent studies and meta-analyses
indicate that sleeping problems and certain aspects of sleep problems such
as sleep duration and the need for soporifics have a significant association
with suicide risk that is independent of confounders and variables.
Violence and Trauma
Violence and trauma, emotional, physical, and sexual, have been associated
with an increased risk of suicidal behavior, suicidal ideation, and suicide.
These include bullying and cyber-bullying, exposure to interpersonal
violence, intimate partner violence, dating violence, post-traumatic stress
disorder, childhood abuse and maltreatment, and sexual assault.
Borderline Personality Disorder and Suicide
Borderline personality disorder is defined (in part) by the DSM-5 as: A
pervasive pattern of instability of interpersonal relationships, self-image, and
affects, and marked impulsivity... People who have borderline personality
disorder have a high risk for suicidal behavior and suicide, and the risk may
be increased by comorbidity with alcohol misuse, anxiety disorder, bipolar
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disorder, major depressive disorder, post-traumatic stress disorder, and
substance use and addiction disorders.
Eating Disorders and Suicide
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) describes eight eating disorders and notes that: Feeding and eating
disorders are characterized by a persistent disturbance of eating or eatingrelated behavior that results in the altered consumption or absorption of
food and that significantly impairs physical health or psychosocial
functioning. Three of the eight eating disorders, anorexia nervosa, bulimia
nervosa, and binge eating are of specific interest here for two reasons:
1. Eating disorders are relatively common. The lifetime prevalence of
anorexia nervosa and bulimia nervosa in women in the U.S. has been
estimated to be 4% and 2%, respectively, and similar figures have been
reported in other areas of the world. Binge eating is the most common of
the three, but it appears that suicide issues are less common with this
eating disorder.
2. Eating disorders and suicide are closely related. Suicidal ideation, suicidal
behavior, and suicide are common in people who have an eating disorder
even after adjusting for comorbid conditions such as anxiety disorder,
major depressive disorder, and substance use. Potzky, et al. noted that
11.8% of patients with an eating disorder had attempted suicide and
43% had experienced suicidal ideation.
Behaviors, comorbidities, demographic characteristics, and life experiences
that may increase the risk of suicide in people who have an eating disorder
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include (but are not limited to): adolescence, alexithymia (inability to
recognize or describe one's emotions), borderline personality disorder,
childhood physical or sexual abuse, depressive symptoms, excessive
exercise, the use of laxatives and other purging behaviors, previous suicide
attempts, and substance use. Research using the Australian Twin registry
suggest that in women who have an eating disorder there is a genetic
influence relative to suicidality.
The association of binge eating with suicidal ideation, suicidal behavior, and
suicide has been less well studied. Sheehan and Herman’s literature search,
covering 2003-2014 identified three articles that had pertinent information.
One study found 6.7% of women with a binge eating disorder had made a
suicide attempt. A sample of an adult outpatient population who had binge
eating disorder found that 28% of the patients had had suicidal ideation;
and, a study of Swedish twins found that women who had binge eating
disorder and major depressive disorder had a higher suicide attempt and
completion rates than women who had binge eating disorder but not major
depressive dsorder.
Traumatic Brain Injury and Suicide
Traumatic brain injury (TBI) is a common injury that is caused by violent
external force to the head. Blunt trauma, acceleration or deceleration, or
exposure to a blast (as in a war zone) causes injury to the brain, resulting in
neurologic dysfunction, confusion, and a change in consciousness that is
temporary or permanent.
Traumatic brain injury can be mild, moderate, or severe. In the U.S. the
incidence of TBI is between 18 and 250 per 100,000 persons per year, and
these are associated with significant morbidity and mortality. People who
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have had a TBI are at high risk for cognitive, emotional, physical, and
psychiatric disorders, including suicide. The link between TBI and the risk for
suicide is very strong, and research has consistently shown that people who
have a TBI have much higher rates of suicidal ideation, suicidal behavior,
and suicide than the general population. The presence of alcohol use
disorder, anger and aggression, depression, severity of injury, and
substance use in combination with TBI increases the risk for suicide.
Suicidal ideation and attempts may be directly associated with the
consequences of TBI. These include the physical effects, such as change in
eyesight (limiting driving ability and independence), difficulty with balance
and coordination, and inability to use certain motor functions, cognitive
effects, such as difficulty concentrating, making decisions/judgments, selfexpression, or aphasia, and mood-related changes, including apathy,
anxiety, emotional lability, and depression.
Emotional Regulation and Suicide
Emotional regulation has been defined in technical terms, but for the
purposes of this course, emotional regulation can be considered the
behaviors and strategies used to cope with emotions. In essence, emotional
regulation relates to how individuals control emotions so that emotions do
not control them. Simple examples of positive/functional emotional
regulation are cognitive reappraisal, emotional awareness and problem
solving; and, examples of negative/dysfunctional emotional regulation are
emotional suppression and avoidance.
Negative emotional regulation is a common feature of anxiety disorder,
bipolar disorder, borderline personality disorder, depressive disorder, eating
disorders, PTSD, and other psychiatric illnesses that are strongly associated
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with suicide, and studies of some populations have shown that improving
emotional regulation can reduce suicidal ideation and suicide attempts.
Dysfunctional emotional regulation increases the risk for suicide, suicidal
behavior, and suicidal thoughts.
The Risk For Suicide In Special Populations
The following case vignette highlights the vulnerability of lesbian, gay,
bisexual, and transgendered (LGBT) individuals, but there are many specific
populations in our society in which the risk of suicide is particularly high.
This section will discuss these at-risk populations.
Case Vignette
Rutgers University made headlines in 2010 due to the suicide of freshman
student Tyler Clementi, who killed himself by jumping from the George
Washington Bridge. Tyler reportedly was distraught when his roommate
broadcast intimate footage of Tyler and another young man. Tyler’s death
brought national and international attention to the issue of cyber bullying and
the struggles facing LGBT youth.
Lesbian, Gay, Bisexual and Transgendered
Lesbian, gay, bisexual and transgendered (LGBT) individuals have a far
higher risk of suicide than heterosexuals. Researchers found that close to
one-fourth of the LGBT adult population surveyed had attempted suicide and
that there was an association between sexual minority status and suiciderelated behavior. It is not clear if LGBT individuals complete suicide more
than other population groups.15,16
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Factors that increase the risk of suicide for LGBT individuals (but are not
limited to) include an earlier time of coming out, lack of community and
family acceptance, isolation, negative self-image, physical and sexual abuse,
a greater incidence of alcohol and PTSD, substance use, victimization, and a
higher incidence of anxiety disorder, depressive disorder, and other
psychiatric disorders.
The higher incidence of significant psychiatric disorders is particularly
concerning as these are well known to increase the risk of suicide. Bostwick,
et al. (2014) noted that mental health disparities in sexual minorities are
well documented and that numerous studies … have demonstrated
heightened prevalence of depressive and anxiety disorders among lesbian,
gay, and bisexual groups as compared with heterosexuals.87 Haas, et al.
opined that … elevated rates of mental disorders, including substance use
disorders, have also been reported in one-quarter to one-third of LGB adult
respondents in large-scale health surveys that have defined sexual
orientation based on self-identity.88 This disparity has been explained by the
greater number of personal and social stressors that LGBT individuals must
contend with and their relative lack of social support.
Childhood Sexual Abuse
Childhood sexual abuse is a strong predictor for suicidal behavior and
suicide, and victims of childhood sexual abuse are at increased risk for
developing behavioral problems and serious psychiatric disorders such as
borderline personality disorder, depression, PTSD, and substance use that
predispose to suicide. Early onset, duration, severity, and the identity of the
perpetrator appear to increase the risk for suicidal behavior and suicide.
Elderly
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The rates for suicide are highest for middle age and older adults, and the
increased suicide rate in the U.S. is especially pronounced in older adults.
Older adults and the elderly also have comparatively more completed
suicides, one completion for every four attempts, and a much lower ratio
than that of the general population. There is also evidence that suggests
that suicide in the elderly is underreported, and researchers have found that
suicidal behavior in older adults is associated with many factors, including
specific illnesses such as COPD and malignancies, pain and functional
disabilities.46,47
Factors that increase the risk of suicide for the general population, such as
isolation, psychiatric disorders, and substance use are relatively common in
older and elderly adults and increase their risk, as well. But older and elderly
adults react differently to some of these issues, and aging presents stressors
that can increase the risk of suicide specific to this population.
Cognitive changes are a common feature of aging, and these may be a
factor in the high rates of suicide in older and elderly adults. For example,
cognitive impairment and dementia, both relatively common in these
populations, have been identified as risk factors for suicide. The early stage
of dementia when awareness is less affected and a comorbid condition of
depression appear to particularly increase the risk of suicide in older adults.
In addition, psychiatric disorders such as depression are common in people
who have cognitive impairment, dementia and depression, which is a suicide
risk factor. Physical illnesses and functional disability in older and elderly
adults have been strongly associated with an increased risk of suicide.
Adolescents
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Suicide is the third leading cause of death in adolescents and for adolescents
15–19 years of age it is the second leading cause of death. Adolescents are
less likely to complete suicide, with the ratio of attempts to completed
suicides estimated to be from 50:1 to 100:1, but as with other groups there
is evidence that adolescent suicides are unreported therefore the risk and
the total numbers may be higher. Adolescents are subject to many of the
same risk factors for suicide as other defined groups and the general
population. But there are also suicide risk factors that are specific to this age
group and some that are common to all populations but appear to be
particularly dangerous for an adolescent.3,41,53,57 Discussed here are bullying
and mood disorders and psychotic symptoms.14
Bullying
Bullying is consistently mentioned as a factor that increases the risk of
suicidal ideation and behavior and suicide in adolescents, and youth bullying
has been described by the National Academies of Sciences as a major and
preventable public health problem.
Bullying can take many forms, i.e., cyberbullying, emotional and relational
bullying, and physical bullying but regardless of how it is done, bullying
involves aggression in the context a power imbalance. The CDC defines
bullying among youth this way: Bullying is any unwanted aggressive
behavior(s) by another youth or group of youths who are not siblings or
current dating partners that involves an observed or perceived power
imbalance and is repeated multiple times or is highly likely to be repeated. It
is not known how often adolescents suffer from bullying, but researchers
have found that a significant percentage of the adolescent population have
been victims of cyber-bullying as well as victims of traditional bullying.
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Factors that increase the risk of bullying victimization in adolescents include
(but are not limited to) depression, low self-esteem, obesity, real or
perceived differences, sexual minority status, and social isolation increase
the risk of being bullied.
Mood Disorders and Psychosis
Mood (affective) disorders, particularly bipolar disorder and depression, are
significant risk factors for suicide, and these psychiatric illnesses are very
common in adolescents who commit suicide. Psychotic symptoms are not
uncommon in adolescents. Kelleher, et al. in a meta-analysis found that in
adolescents 13–18 there was a 7.5% median prevalence of psychotic
symptoms in adolescents 13–18 years of age. These symptoms are intensely
troubling and dangerous for anyone, and perhaps more so for adolescents.
Kelleher, et al. interviewed 423 adolescents in two separate studies, one
group being 11–13 years of age, and the other being 13-15 years of age.
The authors reported that the presence of psychotic symptoms greatly
increased the risk of suicidal behavior, and the risk for suicidal behavior in
adolescents who had suicidal ideation. The authors also opined that when
directly questioned, most adolescents with suicidal plans and acts reported
psychotic symptoms, in particular auditory hallucinations. Kelleher also
confirmed the seriousness of psychotic symptoms in adolescents, noting that
adolescents with psychopathology who reported psychotic symptoms had a
nearly 70-fold increased odds of acute suicide attempts.
Homelessness
Homeless Americans are especially vulnerable to suicide. They have a far
greater incidence of many of the risk factors for suicide such as serious
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psychiatric illnesses, chronic illnesses, unemployment, traumatic life events,
and alcohol and substance use. In addition, the homeless appear to be less
resilient to these issues, and the multitude and intensity of these stressors
has a predictable and tragic result. Homeless individuals have a much higher
rate of suicidal thoughts and behavior and suicide itself than the general
population; researchers have found that homeless individuals were twice as
likely as the non-homeless to kill themselves and a significant percentage of
adults living in a homeless shelter had attempted suicide.51,90,148
Incarceration
Suicidal ideation and behavior and suicide are common in people who are, or
have been incarcerated. Casiano, et al. found that suicide was the number
one cause of death among incarcerated youth.149 Research on factors that
influence and/or increase the risk has produced (somewhat) conflicting
results. A combination of individual and environmental factors likely
accounts for the higher rates of suicide in correctional settings.
Jails and prisons contain vulnerable groups that are traditionally among the
highest risk for suicide, including young males, persons with mental
disorders, people who are socially disenfranchised or socially isolated, people
with substance use problems, and those who have had previous suicidal
behaviors. Another common factor was that many of the inmates who had
committed suicide had been held on or convicted of violent charges.
However, depression and previous inpatient psychiatric treatment have
consistently been identified in incarcerated individuals who have suicidal
ideation and behavior or have completed suicide.52
There are also contextual issues that could influence suicidality among
incarcerated individuals. Some of these include overcrowding, lack of
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possibility of purposeful activity, sanitation, broad sociocultural conditions,
the prevalence of HIV/AIDS, levels of stress, and access to basic health or
services for mental health or substance use issues. Prisons are also
characterized by social isolation and violence.
Youth in Foster Care
There is also concern that youth in the foster care system may be at an
increased risk for suicidal behaviors and other related problems. Each year
millions of children are abused at home and by necessity placed into the
foster care system. Adolescents who have been in foster care are much
more likely to have seriously considered suicide or attempted suicide than
other youth. Anxiety, depression, and substance use, strong risk factors for
suicide, and emotional and behavioral problems are more likely to be
present in children and adolescents who are in foster care.53
While the home environment is not a positive one for youth in foster care,
many youth in the system still struggle with separation from their other
caregivers and supports (friends, school supports such as teachers, and
neighbors). They may also experience further maltreatment in foster care,
and may frequently be moved from home to home. These experiences may
result in a sense of loss. They may also carry the shame of being placed in
foster care. These experiences of loss, isolation, and lack of social support
are all risk factors for suicide. Other common risk factors among youth in
foster care include:53

Mental illness including substance use

Access to medications

Prior suicide attempt
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
Self-injury

Parental mental illness and substance use

Family conflict and dysfunction

Family history of suicidal behavior

Poor coping skills

Social alienation

Exposure to suicides and attempts

Suicide means availability (access to lethal means)

Other risk-taking behaviors (promiscuous sex, driving recklessly,
petty theft, vandalism)

Minority sexual orientation or gender identity

Violence and victimization

Bullying
Physicians
It has traditionally been reported (and there is evidence to support this) that
physicians and physicians in training have a high risk for suicide, higher than
the risk of suicide in the general population. The risk is particularly high for
female physicians.56
The factors that increase the risk of suicide for physicians are often the same
as for the general population, i.e., depression, alcohol and substance use,
but as with many of the other specific groups discussed in this course, these
stressors are more common in physicians and physicians in training than in
the general population. But physicians also have two stressors that increase
the risk of suicide, stressors that are not unique to this group but are
especially pronounced for them; burnout and stigma.
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The rate of professional burnout is very high in physicians and the stigma of
having mental illness or suicidal ideation is also very high in this group. It is
a dangerous combination; high levels of stress and burnout, higher than
average incidence of risk factors for suicide, shame and stigma at having a
mental illness and/or suicidal thoughts, and a natural reaction to the shame
and stigma and unwillingness to seek help.
Culture And Ethnicity As Risk Factors For Suicide
While prevalence data outlines the
increased vulnerability of certain
ethnic and cultural groups, it does
not necessarily provide insight into
culturally relevant risk and
protective factors. It is important
that clinicians treat suicidality from a
culturally competent perspective.
Additionally, there are many myths
associated with various ethnic
groups and suicide risk, (for
example, a belief that because Hispanics are predominately Catholic, suicide
is not a problem) that may incorrectly influence therapists. This section
provides an overview of suicidality among certain ethnic groups.3,61-74
American Indians
American Indians have a higher rate of suicide than other ethnic groups in
the U.S. The risk is especially high for adolescents and young adults but
unlike other groups, suicide in older American Indian adults is less prevalent.
Interestingly, suicidal ideation appears to be less common for this group.
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Suicide risk factors for American Indians are much the same as for the
general population and for other ethnic groups; alcohol and substance use,
bullying, economic stress, personal loss, poor or no access to mental health
services, previous suicide attempts, psychiatric illnesses, sexual abuse,
social isolation, and racism. Other individual risk factors that apply to both
youth and adults in Native American families include feeling disconnected
from family, feeling that one is a burden, unwillingness to seek help because
of stigma attached to mental and substance use disorders and/or suicidal
thoughts, and concerns associated with suicide contagion or cluster suicide.
However, as with other specific populations and ethnic groups, some of
these risk factors are more common in American Indians than in the general
population, explaining in part why American Indians have a high rate of
suicide.
The role of historical trauma is one that is affects American Indians and
merits additional consideration. Broadly defined, historical trauma is defined
as an event or events that affect multiple generations of a culture. For
American Indians, there has been the historical trauma of forced relocation
known as the Trail of Tears. The Indian Removal Act of 1830 mandated
relocation of members of the Cherokee, Muscogee, Seminole, Chickasaw,
and Choctaw nations from their ancestral homelands in the southeastern
U.S. to an area west of the Mississippi River that had been designated as
Indian Territory. This is one widespread example of such actions.
A related trauma was the removal of children who were sent to boarding
schools during the late 19th and early 20th centuries. Originally established
by Christian missionaries, these Boarding Schools immersed children in
European-American culture through appearance changes with haircuts, a
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ban on speaking their native languages, and traditional names being
replaced with new European-American names. In numerous ways, children
were encouraged or forced to abandon their Native American identities and
cultures. While today tribal nations have increasingly insisted on communitybased schools and have also founded numerous tribal colleges and
universities, these memories are still fresh for many Native American
families.
These experiences may be part of the challenges of help-seeking behaviors
among these groups who may believe these services represent the “white
man’s” system and culture, or that the professionals will not understand
Native ways. Another aspect in recognizing suicidal ideation in Native
American people concerns the politeness theory. In this culture, people
considering suicide may not be direct in making their personal pain known to
avoid placing a burden on others. Additionally, vague or indirect calls for
assistance help protect them from their own embarrassment if others fail to
respond. There is a cultural stigma against suicide and following a suicide
attempt.
Protective factors that have been found to prevent suicide in American
Indians include, but are not limited to: access to mental health case findings
and intervention, services, emotional regulation, family cohesion, respect for
help-seeking behavior, screening, survivor groups, and taboos against
suicide.
Spirituality has also been shown to be a buffer against suicidality in Native
Americans. Due to experiences of assimilation, many Native Americans try to
achieve a spiritual balance between what may be Christian religious
practices while others may be grounded in traditional spiritualism.
Researchers have found that it is important to integrate traditional
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spirituality into the therapy, including the use of traditional healing practices,
sacred rituals, and ancestral knowledge. Examples include the use of the
medicine wheel, the sacred pipe, sweat lodges, the sun dance, the seeking
of a vision, the womanhood ceremony, the throwing of the ball, the keeping
of a spirit, and the making a relative. While there have been many organized
efforts to include these ideas, one that provides a good example is called
Native H.O.P.E. (Helping Our People Endure).
Aimed at youth, Native H.O.P.E. is a curriculum based on the theory that
suicide prevention can be successful in Indian Country when Native youth
become committed to breaking the ‘code of silence’ that is prevalent among
all youth. The program also is premised on the foundation of increasing
strengths among Native youth as well as increasing their awareness of
suicide warning signs. The program supports the full inclusion of Native
culture, traditions, spirituality, ceremonies, and humor. The 3-day Native
H.O.P.E. youth leadership curriculum takes a proactive approach to suicide
prevention. Clinicians may seek more information on Native American client
support, including the American Indian Community Suicide Prevention
Assessment Tool developed by the One Sky Center, a national resource
center for American Indians and Alaska Natives, at the One Sky Center Web
site, www.oneskycenter.org.
African Americans
African Americans are much less likely to have suicidal ideation and to
commit suicide than white Americans. The risk factors for suicide that affect
African Americans are much the same as for the general population but
suicide in the African American population is disproportionately clustered in
adolescents, and racism is a prominent aggravating factor. Racial
stereotypes and negative images can be internalized, denigrating individuals’
self-worth and adversely affecting their social and psychological functioning.
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Racism and discrimination have resulted in minorities’ lower socioeconomic
status and poorer living conditions in which poverty, crime, and violence are
persistent stressors that can affect mental health. Additionally, racism and
discrimination are stressful events that can directly lead to psychological
distress and physiological changes affecting mental health.
African Americans are also significantly overrepresented in the most
vulnerable segments of the population and those previously discussed for
being at high risk for suicide. More African Americans than Caucasians or
members of other racial and ethnic minority groups are homeless,
incarcerated, or are children in foster care or otherwise supervised by the
child welfare system. African Americans are especially likely to be exposed
to violence-related trauma, as were the large number of African American
soldiers assigned to war zones in Vietnam.
Access to mental health services and service utilization also appears to play
a role. African Americans who reported suicidal thoughts or attempts were
less likely than whites to seek or receive psychiatric services. Lack of health
insurance is a barrier to seek mental health care at local health centers.
Significant protective factors found for all populations apply for African
Americans as well, for example, effective and accessible mental health care,
connectedness to individuals, family, community, and social institutions,
problem-solving skills, and contacts with caregivers. Adaptive traditions have
sustained African Americans through long periods of hardship imposed by
the larger society and this resilience is an important protective resource.
Additionally, research has shown significant protective factors in African
American populations, particularly the role of spirituality and religious
beliefs.
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Neeleman, et al. found that the comparatively low level of suicide among
African-Americans involved high levels of orthodox religious beliefs and
personal devotion, evaluated to be protective against suicide, and other
researchers have mirrored these findings. Assari, et al. noted that religiosity
delayed the age of onset and the number of psychiatric disorders.
The role of family support, peer support, and community connectedness
have been shown to help protect African American adolescents from suicidal
behavior. Matlin, et al. studied the relationship between various types of
social support and suicide, and the extent to which support moderates the
relationship between depressive symptoms and suicidality. The researchers
asked 212 African American adolescents to rate three types of social
support: family support, peer support, and community connectedness. The
survey also addressed depressive symptoms and suicidality, as measured by
reasons for living, a cognitive measure of suicide risk. The results indicated
that increased family support and peer support are associated with
decreased suicidality; and, peer support and community connectedness
moderated the relationship between depressive symptoms and suicidality.
Similarly, positive interactions and social and family support have been
shown to significantly reduce risk for suicide attempts among African
American adults.
Hispanic/Latinos
There is a common perception that Hispanic Americans do not commit
suicide due to the strong Catholic restrictions against it. Religiosity is an
important protective factor, but Hispanic Americans are a diverse group and
while suicide rates are lower than other ethnic groups they are not
negligible.
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Compared to white Americans Hispanic Americans are much less likely to
commit suicide. The risk for suicide however is particularly high for Hispanic
American adolescents, particularly girls. Alcohol and substance use are
relatively high among Hispanic youth compared to white and African
American youth, which can certainly be an aggravating factor. The stresses
of acculturation and discrimination have also been found to contribute to the
risk for suicide in Hispanic Americans.
Some researchers have proposed that suicidal behavior among Hispanics
may be connected to a cultural expectation that family needs are placed
above individual needs; suicidality in young Hispanic females may be related
to the stress caused by the expectation of obligation to the family. Access to
and utilization of healthcare resources are also risk factors that affect
Hispanic Americans and may influence the suicide rate in this group,
especially in adolescents.
In some research outcomes, it was noted that Hispanic adolescents were
less likely than other ethnic youths to be identified as suicidal; and, Hispanic
adolescents who had emotional, family, or social issues that might cause
suicidal ideation tended to get help from family and friends.
The immigration status of Hispanic Americans has a somewhat complicated
effect on a suicide. Hispanic immigrants were reported to have a higher
suicide risk that Hispanics born in the U.S., but the risk for suicide was
influenced by population size: immigrants have higher rates overall, this
difference was conditioned by the relative size of the Hispanic immigrant
community; in areas with smaller immigrant populations, immigrants were
at a higher risk of suicide than their native-born counterparts, while in areas
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with larger immigrant populations, the opposite was true — natives were at
a higher risk.
While these barriers are daunting, there are also many protective factors in
Hispanic American culture. The cultural role of familism, which emphasizes
close family relationships and extended family, is crucial to many Hispanics,
and these connections can be very important for protection against
suicide. Moral objections to suicide have also been identified as a protective
factor.
Asian Americans/Pacific Islanders
The last U.S., census was done in 2010 and it estimated there were 17.3
million people of Asian descent and people who identified as Pacific islander
ethnicity living in the U.S. This is a very diverse group that includes
individuals of Cambodian, Chinese Filipino, Laotian, Korean, Asian Indian,
Vietnamese, Japanese, and Pacific Islander, and other Asian descent.
The risk of suicide in this population has usually been determined to be less
than that of white Americans and American Indians and approximately
equivalent to African Americans and Hispanic Americans/Latinos; however,
an unfortunate exception is Asian American adolescents. Like Native
American and Hispanic/Latino adolescents, Asian American adolescents have
a disproportionately high risk for suicide. The 2016 Youth Risk Survey found
that the self-reported incidence of suicide attempts in Asian American
adolescents was 9.5%, or 1.5 times that of white American adolescents.
Risk factors for suicide that appear to be specific to Asian Americans include:
low comparative utilization of mental health resources, lack of culturally
appropriate mental health resources; expressing emotional distress through
physical problems (somatization) and believing that that physical problems
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cause emotional disturbances, cultural stigma of mental illness, financial or
professional failures, real or perceived, that engenders feelings of shame
and failure to meet family and social obligations, cultural norms that inhibit
and discourage expression of suicidal ideation, and interpretation of mental
illness as a personal weakness and as an obstacle that prevents meeting
social and family responsibilities.
Immigration can also be a stressor that increases the risk for suicide.
Zhang, et al. (2013) compared depression, anxiety, and suicidal ideation
among Chinese Americans, looking at immigration-related factors. The
researchers found that U.S. born Chinese and those who immigrated to the
U.S. at 18 years or younger were at higher risk for lifetime depressive or
anxiety disorders or suicidal ideation than were their China-born
counterparts who arrived in the country at or after 18 years of age. For
Chinese Americans, immigration-related factors were associated with
depression and anxiety disorders and suicidal ideation. The researchers
concluded that the higher prevalence of these disorders might be attributed
to the psychological strains experienced by those who are at higher risk of
cultural conflicts.
Protective factors for Asian Americans include the desire to maintain interpersonal and social relationships, an emphasis on self-reliance, and social
support from family and community.
Immigrants
The groups we have discussed to this point have primarily been assimilated
into the U.S. for many years. But in every year since 1990, approximately
one million new immigrants have entered the United States. Immigrants
typically demonstrate strengths and resiliencies, and research suggests that
among these is the motivation to learn English and engage in the labor
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market. However, the act of moving to another country is a stressful life
event. Recently arrived immigrants face many risks, including potential
poverty, discrimination, employment problems and social isolation.
Also, immigration has been found to have many stressors that can heighten
the risk for suicide.
Additional challenges may be connected to the immigration process
(separation from country of origin and families, and navigation of unfamiliar
cultural contexts), and acculturation (language, cultural and ethnic identity,
customs, gender roles, etc.). Intergenerational and familial conflicts may
result from the acculturation process. Many immigrants have also faced
traumatic experiences within their countries of origin. These factors result in
immigrants being at higher risk for mental health problems including
depression and anxiety disorders and posttraumatic stress disorder (PTSD),
all potentially related to suicidality.
Kposowa, et al. looked at the impact of immigration on suicide using an
unmatched case-control design. Data on cases were obtained on suicides in
one county in California from 1998 to 2001. Information on controls was
obtained from the 2000 U.S. Census, and the researchers found that
immigration increased suicide risk. Immigrant divorced persons were over 2
times more likely to commit suicide than natives. Single immigrants were
nearly 2.6 times more likely to kill themselves than the native-born
Californian. Shorter duration of residence was associated with higher suicide
risk. The authors suggested that integration of immigrants in receiving
societies is important to decrease suicide and that policies aimed at reducing
suicide should target more recent immigrants. While more formal research is
needed, clinicians should consider the effects of immigration as a risk factor
for suicidality.
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Assessing Suicidal Risk
There are many risk factors for suicide, but no single one by itself increases
or decreases risk. Population-based research suggests that the risk for
suicide increases with an increase in the number of risk factors present; the
greater the number of risk factors that are present the more likely there an
increased risk for suicidal behaviors.3,82,115-121,124,143
Acute signs of suicide risk include:

Actively looking for ways to commit suicide such as buying a firearm,
researching suicide methods, and making a plan.

Making threats to commit suicide.

Persistently and actively talking about death and suicide.

Talking, writing or posting on social media about death, dying and
suicide.
Expanded warning signs of suicide include:

Dramatic mood changes

Hopelessness

Increased alcohol and/or drug use

Making arrangements for those who will be left behind

Rage, intense anger

Reckless behavior

Saying goodbye

Social withdrawal
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Chronic/ongoing risk involves feelings and behavior that is experienced over
an extended period. The five key feelings and behaviors are identified in the
Table below.
Feelings
No reason for living, or no sense of
purpose in life
Feeling trapped, like there’s no
way out
Hopelessness
Dramatic mood changes
Behaviors
Increased substance use
Withdrawal from friends, family
and/or society
Rage, anger, revenge-seeking
behavior
Reckless or risky decision making
and actions
Anxiety/agitation
Unable to sleep or sleeping all the
time
Myths and Misconceptions About Suicide
Among clinicians and laypersons a number of myths exist relating to suicide.
Some researches and authors have described some of these myths.

People who want to kill themselves will not talk about suicide:
Research on this idea has yielded mixed results. While some people
actively considering suicide do not seek help, others do. It is always
important to take people seriously when they express suicidal ideation. It
is important not to dismiss talk of suicide as a cry for attention.
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
Suicides increase in fall and winter:
There does appear to be an association between increased suicide risk
and the fall and winter seasons, but research has found that the
association of season to suicide changes with geographical region and
several climatic variables.

An unsuccessful attempt means that the person wasn't serious about
ending his or her life:
Some people are naive about how to kill themselves. The attempt in and
of itself is the most important factor, not the method or outcome.

People who commit suicide always leave notes:
Some people do, while others do not leave a suicide note.

The so-called birthday blues lead to an increase in suicide:
Some researchers have found evidence supporting the idea of birthday
blues increasing the risk of suicide, while some have not; and others have
found it to be true only for certain groups of people.

Using the word suicide with a client will increase the likelihood that
he/she will attempt suicide.
Assessment Process
Suicide assessment for an at-risk client should be an individualized process.
There are many standardized suicide assessment tools that have been
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validated as accurate and can be very helpful, but they are not substitutes
for clinical evaluation.
The information collected during the assessment process allows the clinician
to: 1) Identify specific factors and features that increase or decrease the risk
for suicide or other suicidal behaviors and that can be modified by acute and
ongoing interventions, 2) Address the patient's immediate safety and
determine the most appropriate setting for treatment, and 3) Develop a
diagnosis that will guide treatment.
Goals of the assessment are:

Ask the patient about past suicide attempts and suicidal ideation.

Get the details of the patient’s current suicidal thoughts and plans.

Find out what, if any, comorbid psychiatric illnesses the patient has.

Determine the patient’s level of impulsivity and self-control.

Find out if the patient has ready access to firearms, dangerous
prescription medications, or other means of causing self-harm.

Evaluate for the presence of other risk factors, i.e., alcohol and/or
substance use, recent stressful events, social isolation.

Evaluate for protective factors.

Find out what past medical history (if any) the patient has and if
he/she has any acute or chronic long-term medical problems being
treated.

Ask about basic socio-demographic characteristics as many of these
are factors that can increase the risk for suicide: age, gender,
ethnicity, immigration status, financial health information and
determine if any of these are specific risk factors for suicide.
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The core questions include: Are you thinking about killing yourself? Are you
planning on killing yourself? Some authors have recommended that these
questions be asked with a neutral tone, and view them as an opening for
further dialogue. Some of the possible things that may emerge following the
questions include: 1) A clear denial of suicidal feelings, thoughts, and plans,
2) A clear endorsement of suicidal feelings, thoughts, and plans, or 3) A
vague response that neither endorses or denies suicidality. Clinicians should
be aware that studies have shown that approximately 50%-80% of people
who are thinking about and/or planning suicide will deny this when asked.
Current Presentation of Suicidality
In assessing current presentation of suicidality/self-harming behaviors, there
are critical considerations. These include suicidal ideation, planning or
feasibility and intent, lethality of proposed plan, timing, impulsivity and risk
factors, hopelessness, and reasons for living.

Ideation:
Have you ever felt that life is not worth living?
When did these thoughts occur?
What led up to these thoughts?
Have you discussed these thoughts with anyone?

Planning/Feasibility:
Do you have a specific plan? What is it? When are you
considering carrying it out?
Do you have the means to carry it out?
Have you ever tried to carry out the plan? Rehearsed it in any
way?
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Are you engaging in behaviors such as getting your affairs in
order, saying goodbyes, writing notes, giving things away?
Is there anything that stops you from carrying out this plan?

Intent:
On a scale of 1-10, how likely are you of carrying out this plan?
If there were another solution to your problem(s) would you take
it?
How often are these thoughts occurring? Do they occur in
specific instances?
Do you have a will?

Lethality of Proposed Plan:
Elicit plan details, and determine degree of lethality associated
with method. Assess: Is death likely to result? How completely
have they researched the method (i.e., Internet, books)? If
intervention occurs, will the person still die?

Protective factors:
What would be a deterrent to killing yourself? Why?
Assess for specific factors: Morality, fears of death,
family/children, friends, job, and importance to others, and
cultural or religious beliefs about death or suicide
Suicidal History
The clinician should ask about previous suicide attempts, suicidal ideation,
and self-harming behaviors. In assessing previous attempts, the number of
attempts, severity/lethality, circumstances/precipitants, and what happened
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should be documented. Additionally, post-intervention, feelings after the
attempt, and any information about support, including family/friends,
previous therapy should be determined.
Multi-Association Assessment Guidelines
The American Psychiatric Association, the International Association for
Suicide Prevention, the Substance Abuse and Mental Health Services
Administration (SAMHSA), and the World Health Organization has suicide
assessment guidelines and information that are free and on-line.
Recommendations for Conducting a Suicide Assessment
As mentioned previously, suicide assessment is something that is highly
individual to each clinician and to each clinical case. There are some
guidelines that can be used to support and facilitate the information
gathering process.

The clinician should adopt a neutral, nonjudgmental stance to
encourage honesty and openness on the part of the client.

Developing and maintaining a good therapeutic alliance enhances risk
assessment.

The clinician should avoid an interrogational style when asking
questions. Encourage a comfortable conversation.

The therapist should strive to instill hope, especially in the future.

It is important to convey that the assessment is only the first step in
the overall process.
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
The clinician should commend the client for honesty in thoughts and
feelings.
During a crisis situation, the clinician should be mindful of actions to avoid:

Marginalizing the client through adopting a stance of power and
authority.

Contributing to the stigma of suicide by shaming a client.

Superficial reassurance and minimization of intense affect. While it is
important to be hopeful, it is equally important not to minimize difficult
and intense emotions.

Avoid passivity. The best therapeutic approach is active and direct.
Documentation
It is important to thoroughly document the assessment. Suicide assessment
is an ongoing process and its documentation will occur after an initial
evaluation or, for patients in ongoing treatment, when suicidal ideation or
behaviors begin or when there is significant worsening or unanticipated
improvement in the patient's condition.
Estimation of Suicide Risk
Following the assessment, the clinician must make an estimate of suicide
risk. While a portion of this assessment certainly rests on sound clinical
judgment, the following factors are helpful to consider. The following factors
in the Table below have been found to increase suicide risk.
Suicidal Thoughts/Behaviors
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Suicidal ideas (current or previous)
Suicidal plans (current or previous)
Suicide attempts (including aborted or interrupted attempts)
Lethality of suicidal plans or attempts
Substance abuse
Suicidal intent
Psychiatric illnesses
Chronic suicidality or manipulative suicidality
Psychiatric diagnoses associated with a high suicide risk include:

Major depressive disorder

Bipolar disorder (primarily in depressive or mixed episodes)

Schizophrenia

Anorexia nervosa

Alcohol use disorder

Panic disorder

Eating disorder (particularly connected to weight gain)

Other substance use disorders

Cluster B personality disorders (particularly borderline
personality disorder)

Comorbidity of mental health disorders
Physical illnesses and factors associated with suicide risk include:

Diseases of the nervous system

HIV/AIDS

Lupus

Pain syndromes

Functional impairment

High utilization of medical care
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Psychosocial features to consider when evaluating suicide risk include:

Recent lack of social support (including living alone)

Unemployment

Drop in socioeconomic status

Poor relationship with family

Recent stressful life event
Childhood traumas, as well as genetic and familial considerations are
generally needed when evaluating for suicide risk, which include:

Sexual abuse

Physical abuse

Family history of suicide (particularly in first-degree relatives) or
suicide attempts

Family history of mental illness, including affective disorders and
substance use disorders
Psychological features often encountered when a patient reports suicidal
thoughts or intent include:

Depression

Hopelessness

Loss of pleasure or interest in life

Severe anxiety

Acute agitation

Decreased self-esteem

Increased self-hatred/self-loathing

Extreme narcissistic vulnerability

Impulsiveness

Aggression
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Cognitive features encountered in a suicidal patient may include:

Loss of executive function

Thought constriction/inability to see alternatives to present
situation

Polarized thinking
Thought patterns in a high-risk suicide patient involve:

Idea that death may be a “way out” of terrible psychological pain

Fantasies of death as an escape

Feeling that he/she is a source of shame to his/her family

Having suffered a recent humiliation
Demographic features of higher risk patients for suicide include:

Male

Widowed, divorced, or single marital status, particularly for men

Elderly age group (age group with greatest proportionate risk for
suicide)

Adolescents and young adults

White race

GBLT orientation
Additional features when considering suicide risk should include:

Access to or availability of lethal means (purchasing or having
available a gun, rope, poison)

Substance intoxication

Recent discharge from a psychiatric hospital (many suicides
occur within 3 months of discharge)

Unstable or poor therapeutic relationship
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
Absence or limited meaningful supportive relationships

Be sure to screen for positives, i.e., “What is keeping you alive
right now?”
Therapeutic Rapport And Patient Alliance
One of the challenging aspects of
suicide prevention is that people who
consider suicide do not always seek
counseling. Earlier researchers found
that people who took their lives often
did not directly communicate their
suicide intent to anyone. Older adults, a
group that has a high risk for suicide,
are comparatively less likely to express
suicidal ideation.
The relationship between the clinician
and the patient is probably the most
important factor in the assessment and
treatment of suicidal behavior. In Practice Guidelines for the Assessment and
Treatment of Patients with Suicidal Behaviors, the American Psychiatric
Association acknowledges that a positive and cooperative psychotherapeutic
relationship can be an invaluable and even life-sustaining force for suicidal
patients.77-82
It is helpful to communicate an empathic but clinically sound path during the
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assessment process. The clinician begins to develop therapeutic rapport
from the first moment he or she meets the client. Some rapport building
strategies include:

Explain the purpose of the assessment

Ask the client for their preference on how they would like to be
addressed (especially a culturally diverse client)

Use a calm, neutral and reassuring tone of voice

Listen deeply
Initial Care
Patient safety is the first priority, and the first step in the management of
suicidal patients is to determine the intensity and the immediacy of risk. If
outpatient treatment strategies are unsuccessful or suicide risk is imminent,
the clinician should consider hospitalizing the patient in a secure inpatient
setting. For example, if the patient has attempted suicide, if he/she has a
detailed plan and the means to carry it out, hospitalization is warranted, or if
the patient has psychosis and made a suicide attempt and/or has a detailed
plan, he/she should be hospitalized.
Additional considerations that indicate the need for hospitalization include:

Suicide threats are escalating and the patient is determined to be a
risk to self or others.

The patient is on psychotropic medications and has previously used
medications with intent to cause self-harm.

The suicidal patient is not responding to outpatient treatment and
there is severe depression or disabling anxiety.

The patient is in an overwhelming crisis and cannot cope without the
risk of serious harm to him or herself and no other safe environment
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can be found.

The risk of suicide outweighs the risk of hospitalization.
While inpatient hospitalization is needed in these situations, it is important
to note that for some patients there is an increased risk of suicide following
inpatient care. This may be due to a short length of stay, lack of continuity
of care after discharge, non-adherence with the treatment plan, and patient
factors present on admission such as a relatively high level of depression,
hopelessness, and impulsivity. Somewhat paradoxically, suicide completers
also evidenced fewer previous suicide attempts and less suicidal ideation
compared with living subjects who had attempted suicide at the time of
index assessment. Thus, it is important not to assume that a person does
not require further monitoring and assessment following discharge.
Outpatient Treatment
Hospitalization also carries the added burdens of increased financial costs
and social stressors resulting from missed work, inability to take care of
personal responsibilities, and possible stigma. If the patient is not considered
to have a high or immediate risk for suicide, outpatient treatment is an
option.
Outpatient Management of Suicidality
The clinician should conduct an evaluation for suicidal ideation/plans,
address factors that directly contribute to risk, get a medication referral (if
needed) to treat underlying disorder(s), encourage increased social support
from the patient’s friends and family, and provide individual and family
(where indicated) therapy. Concurrent substance use can greatly increase
the risk of suicide so if the patient has a substance use problem, addressing
this should be a priority. Keep accurate and current records and carefully
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and continually document all findings. Arrange for emergency coverage for
evenings and weekends. Other important points include:

When imminent risk does not dictate hospitalization, intensity of
outpatient treatment should increase. This should include more
frequent appointments or telephone contacts.

If the target is reduction of suicide attempts and behaviors, treatment
should focus on identified skill deficits such as difficulties with
problem-solving, effectiveness, anger management, or emotional
regulation.

Follow up should be employed to avoid the patient dropping out of
treatment prematurely.

Extended evaluation may be necessary, and suicide risk should be
monitored on an ongoing basis.

A strong therapeutic alliance should be developed with the suicidal
patient. Use the clinical relationship to support safety during times of
crisis.

Involvement of family members, including parents or guardians in
treatment is important. Their contribution should be acknowledged and
they should be empowered to have a positive influence on the patient.
Therapy
There are many treatment approaches that are helpful for treating suicidal
patients. In working with acutely suicidal clients, a dual approach of
psychotherapy and medications is most helpful.
Psychopharmacology And Therapeutic Models
Lithium
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Lithium carbonate has been used since the late 1940s to treat people who
have bipolar disorder, and it can reduce the number and severity of the
depressive and manic episodes that characterize this disease. There is also
good evidence that lithium can prevent suicide in people who have unipolar
and bipolar mood disorders, and although this is not a labeled use for
lithium, it is often recommended for this purpose. Recent literature reviews
and a meta-analysis of 48 randomized controlled trials found that lithium
was an effective treatment for reducing the risk of suicidal behavior in
people who have mood disorders, possibly by its effect as a mood stabilizer
and by reducing aggressiveness and impulsivity.156,158
Antidepressants
Depression is a risk factor for suicide and although the magnitude of its
effect is unclear, antidepressants have been shown to be effective at treating
depressive disorders. A logical and intuitive inference from those facts would
be that antidepressants might help to prevent suicide. But can they?
There is evidence that antidepressants are associated with a slightly higher
risk for suicide in adolescents and young adults. Antidepressants are
associated with a protective effect against suicide in older adults; and,
pharmacoepidemiologic studies have shown that antidepressants have a
protective effect against suicide. However, the up-to-date literature is
unequivocal on the issue; the current data cannot be used to conclude that
antidepressants decrease or do not increase the risk for suicide.158
Antipsychotics, Anticonvulsants and Sedative-hypnotics
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The antipsychotics, anticonvulsants, and sedative-hypnotic drugs have been
used to treat suicidal patients. The evidence indicates that their effect for
this purpose is weak and inconsistent and based on limited research.158
Psychotherapy: Models of Therapy
Edward Shneidman was a seminal researcher and theorist in the field of
suicidology. Shneidman felt that the primary cause/causes of suicide was not
psychiatric illnesses such as depression or schizophrenia but a condition he
called psychache. Psychcache is the hurt, anguish, soreness, aching
psychological pain on the psyche – the pain of excessively felt shame, or
guilt, or humiliation, or loneliness, or fear, or angst, or dread of growing old
or of dying badly, or whatever. People commit suicide, according to
Shneidman, when someone can no longer bear the burden of his/her
psychache; suicide is then the logical choice to reduce the tension and pain.
Campos, et al. discussed psychache as a distinct construct ... a mental pain
that is deeper, more primal, and more savage than general distress or
depression, although general distress or depression may also be present.157
Shneidman opined that suicide prevention is primarily a matter of
addressing and partially alleviating those frustrated psychological needs that
are driving the person to suicide. In retrospect, in almost every case I have
ever seen, it appears that suicide is pushed by pain, and that suicidal
fantasies and suicidal acts are efforts to escape or put a stop to the pain that
flows through the mind.
Shneidman identified many needs associated with psychache and suicide. He
felt the most important ones are:

Counteraction: The need to atone for failure.
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
Affiliation: The need to belong.

Defense: The need for self-protection against harm and threats.

Inviolacy: The need for autonomy and independence.

Shame-avoidance

Succor: The need to be loved and valued.

Order and understanding: The need to understand the inner and outer
world.
The concept of psychache has been identified as an accurate identifier of
suicide risk, and research has shown a strong link between the presence or
strength of psychache and suicidal behavior.157,160
Collaborative Assessment and Management of Suicidality (CAMS)
The Collaborative Assessment and Management of Suicidality (CAMS) is an
evidence-based clinical intervention for suicidal patients. The basic
framework of CAMS is a patient-clinician relationship that emphasizes
collaboration and understanding.153,154 The therapist and the patient work
together - collaborate - on an assessment of the patient’s suicidal ideation
and behaviors using an assessment tool called the suicide status form. When
the level of risk has been established, an appropriate therapeutic
intervention is applied and the patient is actively included, or collaborates,
as a co-author of the treatment process.
Essential to the success of CAMS is a strong therapeutic relationship based
on understanding. Suicide is not a desirable response or one that a therapist
would like to see occur. But it should be emphasized to the client that
he/she understands and empathizes with suicidal feelings. When therapists
understand how suicide is in a sense functional for the patient – as an
escape from psychic pain - they are better positioned to propose alternative
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and less life-threatening ways of coping. During therapy sessions, the
therapist tracks the patient’s suicidal ideation, and if after a certain period
there are no suicidal thoughts, feelings, or behaviors the suicide risk is
considered absent. Clinical trials have shown that CAMS can be effective.
Cognitive Behavioral Therapy
Cognitive-behavioral therapy (CBT) is a problem solving and action oriented
approach to therapy. It is based on the principle that cognitive
characteristics such as rigidity, poor problem solving and coping skills, and
thought distortions are the source of the troublesome and maladaptive
behavior; and the CBT therapist uses this framework as a way to reduce
suicidal ideation and related symptomatology such as depression,
hopelessness, and loneliness.153,154
People who are suicidal often have a negative view of themselves and the
future, and they have irrational beliefs and ways of viewing the world that
lead to hopelessness. The goal of CBT is identifying these issues and
developing coping strategies that are specific to the cognitive distortions and
deficits that drive suicidal ideation and behavior. In CBT, patients are
actively challenged on their negative beliefs and their tendency to view
themselves, their circumstances and their future in unrealistically negative
terms. Patients focus on skills such as problem solving, coping,
assertiveness, and interpersonal communication. In this approach, therapists
actively educate patients about suicide, and the therapists teach them to
recognize and understand their own self-limiting and negative beliefs.
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Clinical guidelines for CBT in suicidality are like those for depression or
anxiety, and include targeting automatic thoughts, summarizing, and
providing homework assignments to practice strategies and techniques
outside of session. Additionally, guidelines state that CBT treatments target
suicidality directly, rather than as a symptom of another presenting disorder.
Thus, treatment needs to be implemented around the client's suicidality.
Many of these guidelines have been applied to adult populations. Several
researchers/clinicians have looked at adolescents with suicidal behaviors to
assess the efficacy and develop treatment protocols for this population. For
example, a manualized CBT approach for adolescents who had attempted
suicide was designed to help adolescents use more effective means of coping
when faced with stressors and problems that trigger suicidal crises, and the
primary focus was reducing suicidal risk factors, enhanced coping, and
preventing suicidal behavior. Parental involvement was included, as well, in
family sessions focused specifically on suicide risk reduction strategies.
A central focus of the manualized approach is the identification of risk factors
and stressors, including emotional, cognitive, behavioral, and family
processes active just prior to and following the adolescent’s suicide attempt
or recent suicidal crisis. These include deficits in the adolescent’s abilities or
motivations to cope with suicidal crises. Family issues become addressed to
the extent that they are relevant to the case conceptualization and the
prevention of future suicide attempts. The initial phase of acute treatment
occurs during the first three sessions and consists of five main components:
Chain Analysis, Safety Planning, Psychoeducation, Developing Reasons for
Living and Hope, and Case Conceptualization. During the middle phase of
acute treatment and after the immediate suicidal crisis has resolved, the
primary area of intervention is behavioral and/or cognitive skills training
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using individual or family sessions. The final component of the acute
intervention phase includes a relapse prevention task.
Dialectical Behavior Therapy
Dialectical behavioral therapy (DBT) was developed as a therapeutic
approach for treating people who have borderline personality behavior, and
it has been adapted and used successfully for suicidal and parasuicidal
behavior. Dialectical behavioral therapy includes simultaneous individual and
group treatment modalities, and is based on the principles of cognitive,
behavioral, and interpersonal therapy.153,154
Among chronically suicidal clients, distress tolerance tends to be low and
coping resources and responses are limited. Dialectical behavioral therapy
targets identified skills deficits such as inability or reduced ability for emotion
regulation, distress tolerance, managing impulsivity, problem-solving,
interpersonal assertiveness, and anger management. One of the key driving
concepts of DBT is mindfulness. The patient is encouraged to be aware of
internal and external experiences, how they affect mood and influence
behavior, and to use this information to change troublesome behavior.
Treatment strategies that guide the DBT process are: dialectical strategies,
problem-solving, group therapy, learning and improving social skills,
individual therapy, validation, capability enhancement, relationship
strategies, and contingency strategies.
Dialectical behavioral therapy was developed as a treatment for borderline
personality disorder, but as previously mentioned, it has been shown to be
effective at reducing suicidal ideation and behavior. For example, Linehan, et
al. used DBT to treat 99 women who had borderline personality disorder who
had previously made several suicide attempts or at least one recent (within
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eight weeks) suicide attempt prior to the study. Dialectical behavioral
therapy or DBT plus or minus some of its standard components was found to
significantly reduce the frequency and severity of suicide attempts and
suicidal ideation, the frequency of non-suicidal self-injury, and increase
reasons for living and the use of crisis services.21
Alliance-Based Therapy (ABT)
Alliance-based therapy (ABT) focuses on the therapeutic alliance with
patients to treat suicidal behavior. Alliance-based therapy is guided by a set
of principles that allows therapists to notice, engage and verbalize the
interpersonal meaning of suicide. Through this process, and if there is a
strong therapeutic alliance, suicidality shifts from symptom to interpersonal
communication between the therapist and patient and becomes something
under the patient’s conscious control.153,154
Some of the principles of ABT include:

Differentiate lethal from non-lethal self-destructive behaviors

Offer a non-punitive interpretation of the patient’s aggression

Metabolize the countertransference

Assign responsibility of the preservation of treatment to the patient

Provide an opportunity for repair
Interpersonal Psychotherapy (IPT)
The Interpersonal Psychological Theory of Suicide (IPTS) informs
interpersonal psychotherapy, and the IPTS has been shown to be a useful
and accurate tool for understanding suicide. The IPTS theory states that
suicidal ideation is caused by thwarted belongingness (i.e., lack of social
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contact, loneliness) and perceived burdensomeness (self-hate, a feeling that
one is a burden on others). The act of suicide and suicide behavior occur,
according to ITP, when an individual acquires the capability to commit
suicide. Specifically, the patient has a lowered fear of death because over
time risk factors for suicide have become constant, intense, and unrelieved.
In simpler terms, IPTS states that people commit suicide because they are
lonely, feel that they are a burden, and suicide is preferable to their
pain.153,154
The IPTS principles guide clinicians to look for interpersonal stressors that
may be present in a client’s life. Examples of these stressors include grief,
role transitions, interpersonal disputes, and interpersonal sensitivity (i.e.,
skills deficits). The theory suggests that clinicians be cognizant of their
patients’ levels of belongingness, burdensomeness, and acquired capability
(especially previous suicide attempts), which may aid clinicians in the task of
suicide risk assessment and of target interventions.
Summary
The prevalence of suicide needs to be understood by health clinicians. Many
people attempt suicide, but do not actually complete the attempt. Most
people who die by suicide have risk factors of depression and other
significant mental health issues, a substance use disorder, or a combination
of risk factors. In addition, suicide is a growing concern for clinicians treating
adolescents.
The identification of suicide risk remains among the most important,
complex, and difficult tasks performed by clinicians. Patient suicide can have
profound personal and professional effects, including increased levels of
anxiety and stress, isolation and withdrawal, and damage to clinicians’
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personal relationships. There may also be evidence of depression, a
protracted grieving process, symptoms of posttraumatic stress or vicarious
traumatization.
Therapists working with suicidal clients have many responsibilities. These
include developing a skill set and protocols for treating clients who may be
at risk for suicide, accurately assessing suicidal risk, responding to a
patient’s suicide attempt, and, importantly, implementing self-care activities.
It is important for clinicians to be prepared and to continuously improve their
skills to screen patients for suicidal ideation and behavior. While it may be
challenging for clinicians to balance their own comfort level with the need to
obtain accurate and clear information, with the varied approaches raised
here to help evaluate patient risk, clinicians may focus on developing a
public health perspective to reduce suicide.
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Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
1. The CDC estimates _____ attempted suicides occur per every
suicide death.
a.
b.
c.
d.
4
7
11
18
2. Suicide is the __________ leading cause of death among
adolescents 15-19 years of age.
a.
b.
c.
d.
number one
third
second
fourth
3. Which of the following is defined as “nonlethal intentional selfinjurious behavior”?
a.
b.
c.
d.
Contagion
Parasuicide
Suicidal ideation
Cluster
4. Which of the following is defined as “a phenomenon whereby
susceptible persons are influenced toward suicidal behavior
through knowledge of another person’s suicidal acts”?
a.
b.
c.
d.
Contagion
Parasuicide
Suicidal ideation
Cluster
5. The increased suicide rate in the United States is especially
pronounced in
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a.
b.
c.
d.
teenagers.
middle aged adults.
older adults.
middle aged women.
6. Which of the following is NOT one of the three primary
components of the Cognitive Stress Diathesis Model?
a.
b.
c.
d.
Oversensitivity to signals of defeat
Perceived “no escape”
Perceived “no rescue”
A present/past orientation
7. In the Clinical Stress Diathesis Models, the primary proposed
genetic factors are
a.
b.
c.
d.
aggressive and impulsive.
aggressive and anxious.
anxious and depressive.
depressive and impulsive.
8. _____________ research assesses the degree to which
someone’s surroundings exert a positive or negative influence
depends on individual factors.
a.
b.
c.
d.
Psychological
Sociocultural
Psychodynamic
Epidemiological
9. The presence of ____________ appears to confer an increased
risk for suicidal behavior.
a.
b.
c.
d.
marital discord
financial Stressors
mental illness
chronic pain
10. ___________ typically commit suicide by poisoning.
a. Students
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b. Older males
c. Men
d. Women
11. In addition to hopefulness, the most consistent protective
factors found in suicide research are
a.
b.
c.
d.
employment and physical health.
physical health and social support.
social support and connectedness.
connectedness and employment.
12. Which of the following is a perceived inability to fully experience
unpleasant, aversive or uncomfortable emotions, and is
accompanied by a desperate need to escape the uncomfortable
emotions?
a.
b.
c.
d.
Distress intolerance
Emotional myopia
Dysemotiva
Distress tolerance
13. Several studies suggest that __________ of those who
committed suicide had a psychiatric diagnosis at the time of
death.
a.
b.
c.
d.
over 90%
40%
over half
70%
14. Which of the following is a measure of hopelessness that is a
20-item self-report inventory?
a.
b.
c.
d.
Beck Hopelessness Scale
Rey Hopelessness Inventory
Lawrence Hopelessness Schedule
Brief Hopelessness Checklist
15. A person who has an alcohol use disorder may be more
vulnerable to suicide if that person, among other things, is
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a.
b.
c.
d.
female.
an adolescent.
male, and over 50.
elderly.
16. _________________ was developed as a therapeutic approach
for treating people who have borderline personality behavior
and it has been adapted and used successfully in treating
suicidal and parasuicidal behavior.
a. Alliance-based therapy (ABT)
b. Cognitive-behavioral therapy (CBT)
c. Rational emotive behavior therapy (RET)
d. Dialectical behavioral therapy (DBT)
17. Homeless individuals were _______ likely as the non-homeless
individuals to kill themselves.
a.
b.
c.
d.
less
just as
4 times more
twice as
18. Demographic features of higher risk patients for suicide include
a.
b.
c.
d.
African Americans.
Native Americans.
Caucasians.
Hispanics.
19. One challenging aspect in recognizing suicidal ideation in Native
American people concerns
a.
b.
c.
d.
the politeness theory.
machismo.
spirituality.
a strong sense of individuality.
20. True or False: Hispanic Americans tend NOT to commit suicide
due to the strong Catholic strictures against it.
a. True
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b. False
21. The risk of suicide for Asian Americans/Pacific Islanders has
usually been determined to be less than or equal to other
groups, except for _________________, who have a
disproportionately high risk for suicide.
a.
b.
c.
d.
elderly Asian Americans
Asian American adolescents
elderly men
Asian American women
22. Which of the following is NOT an acute warning sign of suicide
risk?
a.
b.
c.
d.
Hopelessness
Threatening to hurt self
Looking for ways to kill self
Persistently talking or writing about death
23. Which of the following is/are a myth or misconception about
suicide?
a. Using the word “suicide” with a client will increase the likelihood
that they will make an attempt
b. Suicide contracts are the best way to ensure safety
c. Suicides increase in fall and winter
d. All the above
24. Which of the following is NOT a cognitive feature that increases
suicide risk?
a.
b.
c.
d.
Loss of executive function
Thought constriction
Mental retardation
Polarized thinking
25. True or False: Dialectical Behavior Therapy includes
simultaneous individual and group treatment modalities.
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a. True
b. False
26. Which of the following is NOT a principle of Alliance-Based
Therapy?
a.
b.
c.
d.
Identify and dispute negative cognitions
Differentiate lethal from non-lethal self-destructive behaviors
Metabolize the countertransference
Provide an opportunity for repair
27. Which of the following is a school-based prevention program?
a.
b.
c.
d.
SAMHSA
NAMI
SOS
IASP
28. Concern for suicide among adolescents
a.
b.
c.
d.
is a growing concern.
has leveled off.
is in decline because of programs like SOS.
generally affects children over the age of 12.
29. Resilience describes capacities within a person that promote
a.
b.
c.
d.
30.
adverse health outcomes.
positive outcomes.
persistence in suicide attempts.
discourse on suicide ideation.
True or False. Lithium is an effective treatment for reducing the
risk of suicidal behavior in people who have mood disorders,
possibly by its effect as mood stabilizer and but has NO effect on
aggressiveness and impulsivity.
a. True.
b. False.
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CORRECT ANSWERS:
1. The CDC estimates _____ attempted suicides occur per every
suicide death.
c. 11
“Per the Centers for Disease Control and Prevention (CDC)
statistics, suicide was the tenth leading cause of mortality in the
U.S., accounting for 41,149 deaths in 2013. Many people attempt
suicide, but do not actually complete the attempt. These statistics
estimate 11 attempted suicides occur for every suicide death.”
2. Suicide is the __________ leading cause of death among
adolescents 15-19 years of age.
c. second
“Suicide is the third leading cause of death in adolescents and for
adolescents 15–19 years of age it is the second leading cause of
death.”
3. Which of the following is defined as “nonlethal intentional selfinjurious behavior”?
b. Parasuicide
“Parasuicide: any nonlethal intentional self-injurious behavior that
is intended express suicidal feelings but not to cause her. This is
often called a suicide gesture.”
4. Which of the following is defined as “a phenomenon whereby
susceptible persons are influenced toward suicidal behavior
through knowledge of another person’s suicidal acts”?
a. Contagion
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“Contagion: A phenomenon whereby susceptible persons are
influenced towards suicidal behavior through knowledge of another
person’s suicidal acts.”
5. The increased suicide rate in the United States is especially
pronounced in
c. older adults.
“The rates for suicide are highest for middle age and older adults,
and the increased suicide rate in the United States is especially
pronounced in older adults.”
6. Which of the following is NOT one of the three primary
components of the Cognitive Stress Diathesis Model?
d. A present/past orientation
“This model looks at suicidality as resulting from a combination of
neuropsychological deficits in areas of memory, attention or
problem solving along with stressors that result in perceptions of
hopelessness, immovability, or esteem issues. The three primary
components of this model are… Oversensitivity to Signals of
Defeat…. Perceived No Escape…. Perceived No Rescue.”
7. In the Clinical Stress Diathesis Models, people who attempt or
commit suicide may have a pre-disposition to do so because of
_________________ personality traits.
a. aggressive and impulsive
“Clinical stress diathesis models…. is based on the idea that
psychopathology is a necessary, but not sufficient, factor for
suicide. The authors noted that people who attempt to, or do
commit suicide may have a predisposition to do so because of
aggressive and impulsive personality traits.”
8. _____________ research assesses the degree to which
someone’s surroundings exert a positive or negative influence
depends on individual factors.
b. Sociocultural
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“Sociocultural research assesses the degree to which someone's
surroundings exert a positive or negative influence whether an
individual's family, community and country are supportive or
stressful.”
9. The presence of ____________ appears to confer an increased
risk for suicidal behavior.
d. chronic pain
“Patients with serious medical conditions may be at increased risk
for suicide. These include but are not limited to chronic pain,
cancers, HIV/AIDS, lupus, headache, traumatic brain injury,
fibromyalgia, and diseases of the central nervous system such as
Alzheimer’s disease, epilepsy, Huntington’s disease, and multiple
sclerosis.”
10. ____________ typically commit suicide by poisoning.
d. Women
“Men commit suicide at four times the rate of women, but women
are more likely to have suicidal thoughts. Men typically commit
suicide by using a firearm, women by self-poisoning.”
11. In addition to hopefulness, the most consistent protective
factors found in suicide research are
c. social support and connectedness.
“The most consistent protective factors found in suicide research
are social support and connectedness and hopefulness.”
12. Which of the following is a perceived inability to fully experience
unpleasant, aversive or uncomfortable emotions, and is
accompanied by a desperate need to escape the uncomfortable
emotions?
a. Distress intolerance
“Distress intolerance, on the other hand, is a perceived inability to
fully experience unpleasant, aversive or uncomfortable emotions,
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and is accompanied by a desperate need to escape the
uncomfortable emotions.”
13. Several studies suggest that __________ of those who
committed suicide had a psychiatric diagnosis at the time of
death.
a. over 90%
“Most suicide events occur in people who have a psychopathology
such as bipolar disorder or depression, and although the great
majority of people who have a mental disorder do not commit
suicide, the results of several of studies suggest that over 90% of
those who committed suicide had a psychiatric diagnosis at the time
of death.”
14. Which of the following is a measure of hopelessness that is a
20-item self-report inventory?
a. Beck Hopelessness Scale
“Hopeless can be measured using the Beck Hopelessness Scale.
This is a 20-item self-report inventory that measures negative and
positive attitudes about the future in terms of affective, cognitive,
and motivational factors.”
15. A person who has an alcohol use disorder may be more
vulnerable to suicide if that person, among other things, is
c. male, and over 50.
“People who have alcohol use disorder may be more vulnerable to
suicide if they are over 50, male, unemployed and living alone,
experience a major depressive episode, experience a stressful life
event, have poor social support, or have a substance use disorder
or a serious medical illness.”
16. _________________ was developed as a therapeutic approach
for treating people who have borderline personality behavior
and it has been adapted and used successfully in treating
suicidal and parasuicidal behavior.
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d. Dialectical behavioral therapy (DBT)
“Dialectical behavioral therapy (DBT) was developed as a
therapeutic approach for treating people who have borderline
personality behavior, and it has been adapted and used successfully
for suicidal and parasuicidal behavior. Dialectical behavioral therapy
or DBT plus or minus some of its standard components was found
to significantly reduce the frequency and severity of suicide
attempts and suicidal ideation, the frequency of non-suicidal selfinjury, and increase reasons for living and the use of crisis
services.”
17. Homeless individuals were _______ likely as the non-homeless
individuals to kill themselves.
d. twice as
“Homeless individuals have a much higher rate of suicidal thoughts
and behavior and suicide itself than the general population;
researchers have found that homeless individuals were twice as
likely as the non-homeless to kill themselves….”
18. Demographic features of higher risk patients for suicide include
c. Caucasians.
“Demographic features of higher risk patients for suicide include: …
White race.”
19. One challenging aspect in recognizing suicidal ideation in Native
American people concerns
a. the politeness theory.
“Another aspect in recognizing suicidal ideation in Native American
people concerns the politeness theory. In this culture, people
considering suicide may not be direct in making their personal pain
known to avoid placing a burden on others. Additionally, vague or
indirect calls for assistance help protect them from their own
embarrassment if others fail to respond. There is a cultural stigma
against suicide and following a suicide attempt.”
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20. True or False: Hispanic Americans tend NOT to commit suicide
due to the strong Catholic strictures against it.
b. False
“There is a common perception that Hispanic Americans do not
commit suicide due to the strong Catholic strictures against it.
Religiosity is an important protective factor, but Hispanic Americans
are a diverse group and while suicide rates are lower than other
ethnic groups they are not negligible.”
21. The risk of suicide for Asian Americans/Pacific Islanders has
usually been determined to be less than or equal to other
groups; an exception within this community is _____________,
who have a disproportionately high risk for suicide.
b. Asian American adolescents
“Asian Americans/Pacific Islanders: ... The risk of suicide in this
population has usually been determined to be less than that of
white Americans and American Indians and approximately
equivalent to African Americans and Hispanic Americans/Latinos;
however, an unfortunate exception is Asian American adolescents.
Like Native American and Hispanic/Latino adolescents, Asian
American adolescents have a disproportionately high risk for
suicide; the 2016 Youth Risk Survey found that the self-reported
incidence of suicide attempts in Asian American adolescents was
9.5%, 1.5 times that of white American adolescents.”
22. Which of the following is NOT an acute warning sign of suicide
risk?
a. Hopelessness
“Acute signs of suicide risk include: Actively looking for ways to
commit suicide such as buying a firearm, researching suicide
methods, and making a plan. Making threats to commit suicide.
Persistently and actively talking about death and suicide. Talking,
writing or posting on social media about death, dying and suicide.”
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23. Which of the following is/are a myth or misconception about
suicide?
a. Using the word “suicide” with a client will increase the likelihood
that they will make an attempt
b. “Birthday Blues” lead to an increase in suicides
c. An unsuccessful suicide attempt meant the person was not
serious about suicide
d. All the above [correct answer]
“Among clinicians and laypersons a number of myths exist relating
to suicide… authors have described some of these myths following
myths... An unsuccessful attempt means that the person wasn't
serious about ending his or her life: Some people are naive about
how to kill themselves. The attempt in and of itself is the most
important factor, not the method or outcome. The so-called
birthday blues lead to an increase in suicide... Using the word
suicide with a client will increase the likelihood that he/she will
attempt suicide.”
24. Which of the following is NOT a cognitive feature that increases
suicide risk?
c. Mental retardation
“Cognitive features: Loss of executive function; Thought
constriction/inability to see alternatives to present situation;
Polarized thinking”
25. True or False: Dialectical Behavior Therapy includes
simultaneous individual and group treatment modalities.
a. True
“Dialectical behavioral therapy includes simultaneous individual and
group treatment modalities, and is based on the principles of
cognitive, behavioral, and interpersonal therapy.”
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26. Which of the following is NOT a principle of Alliance-Based
Therapy (ABT)?
a. Identify and dispute negative cognitions
“Some of the principles of ABT include: Differentiate lethal from
non-lethal self-destructive behaviors; Offer a non-punitive
interpretation of the patient’s aggression; Metabolize the
countertransference; Assign responsibility of the preservation of
treatment to the patient; Provide an opportunity for repair.”
27. Which of the following is a school-based prevention program?
c. SOS
“SOS is a school-based prevention program that incorporates two
prominent suicide prevention strategies into a single program...”
28. Concern for suicide among adolescents
a. is a growing concern.
“… suicide is a growing concern for clinicians treating adolescents. A
CDC study found that 16% of adolescents in grades 9-12 had
seriously considered suicide and 8% attempted to do so.”
29. Resilience describes capacities within a person that promote
b. positive outcomes.
“Resilience: Capacities within a person that promote positive
outcomes ...”
30.
True or False. Lithium is an effective treatment for reducing the
risk of suicidal behavior in people who have mood disorders,
possibly by its effect as mood stabilizer and but has NO effect on
aggressiveness and impulsivity.
b. False.
“…controlled trials found that lithium was an effective treatment
for reducing the risk of suicidal behavior in people who have mood
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disorders, possibly by its effect as mood stabilizer and by reducing
aggressiveness and impulsivity.”
References Section
The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading. [Please see the Suicide Prevention Resources in the Appendix
attached below].
1.
Kaslow N. Our opportunity to reduce suicide. APA Monitor.
2014;45(4):2014. http://www.apa.org/monitor/2014/04/pc.aspx.
2.
The National Institute of Mental Health (2016). Retrieved online @
https://www.nimh.nih.gov/health/topics/suicideprevention/index.shtml.
3.
Centers for Disease Control and Prevention. Suicide: Facts at a Glance,
2015. https://www.cdc.gov/violenceprevention/pdf/suicide-datasheeta.pdf.
4.
Centers for Disease Control and Prevention. Youth Suicide. March 10,
2015.
https://www.cdc.gov/ViolencePrevention/suicide/youth_suicide.html.
5.
van Heeringen, K. (2012). Stress-Diathesis Model of Suicidal Behavior.
The Neurological Basis of Suicide. Retrieved online at
https://www.ncbi.nlm.nih.gov/books/NBK107203/.
6.
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Appendix
Suicide Prevention Resources
Air Force Suicide Prevention Program
http://afspp.afms.mil
American Association of Suicidology
http://www.suicidology.org/home
American Association of Suicidology
Clinician Survivor Task Force
http://mypage.iu.edu/~jmcintos/basicinfo
.htm
This website offers an Air Force description of
their suicide prevention program and offers
communities a model with elements that can
be adapted for communities.
This organization advance Suicidology as a
science; encouraging, developing and
disseminating scholarly work in suicidology.
Many clinical resources are available.
Develops and provides postvention for
clinicians who had lost a patient to death by
suicide
Charting the future of suicide
prevention: A 2010 progress review
of the national strategy and
recommendations for the decade
ahead
http://www.sprc.org/sites/sprc.org/fi
les/library/ChartingTheFuture_Full
book.pdf
This document reviews developments in the
field of suicide prevention since the National
Strategy for Suicide Prevention was
published.
Depression Screening
http://www.mentalhealthamerica.ne
t/llw/depression_screen.cfm
Mental Health America has a Depression
Screening site as part of their Campaign for
America’s Mental Health. The webpage
educates people about clinical depression,
offers a confidential way for people to get
screened for symptoms of the illness, and
guides people toward appropriate
professional help if necessary.
IASP is dedicated to preventing suicidal
behavior, to alleviate its effects, and to
provide a forum for academics, mental health
professionals, crisis workers, volunteers and
suicide survivors.
The National Suicide Prevention Lifeline
provides confidential support to people in
suicidal crisis 24 hours a day, 7 days a week
(1-800-suicide). It also operates a Veterans
Crisis line (1-800-273-TALK).
A nonprofit, grassroots, self-help, support
and advocacy organization of consumers,
families, and friends of people with severe
mental illnesses, such as schizophrenia,
International Association for
Suicide Prevention (IASP)
http://www.iasp.info/
National Suicide Prevention Lifeline
http://www.suicidepreventionlifeline.org/
National Alliance on Mental Illness
http://nami.org
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major depression, bipolar disorder,
obsessive-compulsive disorder, and anxiety
disorders
S.O.S (Signs of Suicide)
http://www.mentalhealthscreening.o
rg/programs/youth-preventionprograms/sos/
Suicide Prevention Resource Center
http://www.sprc.org/
Substance Abuse and Mental Health
Services Administration (SAMHSA )
http://www.samhsa.gov/
SOS is a school-based prevention program
that incorporates two prominent suicide
prevention strategies into a single program,
combining a curriculum that aims to raise
awareness of suicide and its related issues
with a brief screening for depression and
other risk factors. The educational component
is expected to reduce suicidality by increasing
middle or high school students’
understanding of and promoting more
adaptive attitudes toward depression and
suicidal behavior. The self-screening
component enables students to recognize
depression, suicidal thoughts and behaviors
in themselves, and to find assistance.
Promotes a public health approach to suicide
prevention and includes suicide prevention
basics, news and events, a training institute,
best practices registry, and a library of
resources. There are additional training
documents specific to different ethnic groups
and vulnerable populations.
A division of the U.S. Department of Health
and Human Services, SAMHSA provides
leadership in promoting quality behavioral
health services to local communities
throughout the country, through grants and
funding for research and programs.
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