Suicide and it's Prevention

A suicidal person may not ask for help, but that doesn't mean that help isn't wanted. People who take their lives don't want to die-they just want to stop hurting. Suicide prevention starts with recognizing the warning signs and taking them seriously. If you think a friend or family member is considering suicide, you might be afraid to bring up the subject. But talking openly about suicidal thoughts and feelings can save a life. If you're thinking about suicide, please read Suicide Help or call 1-800-273-TALK (8255) in the U.S.! To find a suicide helpline outside the U.S., visit IASP or Suicide.org [1-5].

The World Health Organization estimates that approximately 1 million people die each year from suicide. What drives so many individuals to take their own lives? To those not in the grips of suicidal depression and despair, it’s difficult to understand what drives so many individuals to take their own lives. But a suicidal person is in so much pain that he or she can see no other option [5-10].

Suicide is a desperate attempt to escape suffering that has become unbearable. Blinded by feelings of self-loathing, hopelessness, and isolation, a suicidal person can't see any way of finding relief except through death. But despite their desire for the pain to stop, most suicidal people are deeply conflicted about ending their own lives. They wish there was an alternative to suicide, but they just can't see one.

Myth: People who talk about suicide won't really do it.

Fact: Almost everyone who attempts suicide has given some clue or warning. Don't ignore even indirect references to death or suicide. Statements like "You’ll be sorry when I'm gone," "I can’t see any way out," - no matter how casually or jokingly said, may indicate serious suicidal feelings.

Myth: Anyone who tries to kill him/herself must be crazy [11].

Fact: Most suicidal people are not psychotic or insane. They must be upset, grief-stricken, depressed or despairing, but extreme distress and emotional pain are not necessarily signs of mental illness.

Myth: If a person is determined to kill him/herself, nothing is going to stop them.

Fact: Even the most severely depressed person has mixed feelings about death, wavering until the very last moment between wanting to live and wanting to die. Most suicidal people do not want death; they want the pain to stop. The impulse to end it all, however overpowering, does not last forever.

Myth: People who die by suicide are people who were unwilling to seek help.

Fact: Studies of suicide victims have shown that more than half had sought medical help in the six months prior to their deaths.

Myth: Talking about suicide may give someone the idea.

Fact: You don't give a suicidal person morbid ideas by talking about suicide. The opposite is true-bringing up the subject of suicide and discussing it openly is one of the most helpful things you can do [12].

Take any suicidal talk or behavior seriously. It's not just a warning sign that the person is thinking about suicide-it's a cry for help. Most suicidal individuals give warning signs or signals of their intentions. The best way to prevent suicide is to recognize these warning signs and know how to respond if you spot them. If you believe that a friend or family member is suicidal, you can play a role in suicide prevention by pointing out the alternatives, showing that you care, and getting a doctor or psychologist involved [13].

Major warning signs for suicide include talking about killing or harming oneself, talking or writing a lot about death or dying, and seeking out things that could be used in a suicide attempt, such as weapons and drugs. These signals are even more dangerous if the person has a mood disorder such as depression or bipolar disorder, suffers from alcohol dependence, has previously attempted suicide, or has a family history of suicide.

A more subtle but equally dangerous warning sign of suicide is hopelessness. Studies have found that hopelessness is a strong predictor of suicide. People who feel hopeless may talk about "unbearable" feelings, predict a bleak future, and state that they have nothing to look forward to [14,15].

Other warning signs that point to a suicidal mind frame include dramatic mood swings or sudden personality changes, such as going from outgoing to withdrawn or well-behaved to rebellious. A suicidal person may also lose interest in day-to-day activities, neglect his or her appearance, and show big changes in eating or sleeping habits [16].

Talking about suicide - Any talk about suicide, dying, or self-harm, such as "I wish I hadn't been born," "If I see you again..." and "I'd be better off dead."

Seeking out lethal means - Seeking access to guns, pills, knives, or other objects that could be used in a suicide attempt

Preoccupation with death - Unusual focus on death, dying, or violence. Writing poems or stories about death

No hope for the future - Feelings of helplessness, hopelessness, and being trapped ("There's no way out"). Belief that things will never get better or change.

Self-loathing, self-hatred - Feelings of worthlessness, guilt, shame, and self-hatred. Feeling like a burden ("Everyone would be better off without me").

Getting affairs in order -Making out a will. Giving away prized possessions. Making arrangements for family members.

Saying goodbye - Unusual or unexpected visits or calls to family and friends. Saying goodbye to people as if they won't be seen again.

Withdrawing from others - Withdrawing from friends and family. Increasing social isolation. Desire to be left alone.

Self-destructive behavior -Increased alcohol or drug use, reckless driving, unsafe sex. Taking unnecessary risks as if they have a "death wish."

Sudden sense of calm - A sudden sense of calm and happiness after being extremely depressed can mean that the person has made a decision to attempt suicide [17].

Speak up if you're worried

If you spot the warning signs of suicide in someone you care about, you may wonder if it’s a good idea to say anything. What if you're wrong? What if the person gets angry? In such situations, it’s natural to feel uncomfortable or afraid. But anyone who talks about suicide or shows other warning signs needs immediate help-the sooner the better [18-20].

Talking to a person about suicide

Talking to a friend or family member about their suicidal thoughts and feelings can be extremely difficult for anyone. But if you're unsure whether someone is suicidal, the best way to find out is to ask. You can’t make a person suicidal by showing that you care. In fact, giving a suicidal person the opportunity to express his or her feelings can provide relief from loneliness and pent-up negative feelings, and may prevent a suicide attempt [21].

Ways to start a conversation about suicide

A. "I have been feeling concerned about you lately."

B. "Recently, I have noticed some differences in you and wondered how you are doing."

C. "I wanted to check in with you because you haven't seemed yourself lately."

D. Questions you can ask:

E. "When did you begin feeling like this?"

F. "Did something happen that made you start feeling this way?"

G. "How can I best support you right now?"

H. "Have you thought about getting help?"

I. What you can say that helps:

J. "You are not alone in this. I’m here for you."

K. "You may not believe it now, but the way you're feeling will change."

L. "I may not be able to understand exactly how you feel, but I care about you and want to help."

M. "When you want to give up, tell yourself you will hold off for just one more day, hour, minute—whatever you can manage [22]."

Do Be yourself

Let the person know you care, that he/she is not alone. The right words are often unimportant. If you are concerned, your voice and manner will show it.

Listen

Let the suicidal person unload despair, ventilate anger. No matter how negative the conversation seems, the fact that it exists is a positive sign [23].

Be sympathetic, non-judgmental, patient, calm, accepting

Your friend or family member is doing the right thing by talking about his/her feelings.

Offer hope

Reassure the person that help is available and that the suicidal feelings are temporary. Let the person know that his or her life is important to you [24].

Take the person seriously

If the person says things like, "I'm so depressed, I can’t go on," ask the question: "Are you having thoughts of suicide?" You are not putting ideas in their head; you are showing that you are concerned, that you take them seriously, and that it's OK for them to share their pain with you.

But don't

Argue with the suicidal person. Avoid saying things like: "You have so much to live for," "Your suicide will hurt your family," or "Look on the bright side [26]."

Act shocked, lecture on the value of life, or say that suicide is wrong. Promise confidentiality. Refuse to be sworn to secrecy. A life is at stake and you may need to speak to a mental health professional in order to keep the suicidal person safe. If you promise to keep your discussions secret, you may have to break your word.

Offer ways to fix their problems, or give advice, or make them feel like they have to justify their suicidal feelings. It is not about how bad the problem is, but how badly it's hurting your friend or loved one.

Blame yourself. You can't "fix" someone’s depression. Your loved one's happiness, or lack thereof, is not your responsibility [27,28].

Respond quickly in a crisis

If a friend or family member tells you that he or she is thinking about death or suicide, it's important to evaluate the immediate danger the person is in. Those at the highest risk for suicide in the near future have a specific suicide PLAN, the MEANS to carry out the plan, a TIME SET for doing it, and an INTENTION to do it.

The following questions can help you assess the immediate risk for suicide:

A. Do you have a suicide plan? (PLAN)

B. Do you have what you need to carry out your plan (pills, gun, etc.)? (MEANS)

C. Do you know when you would do it? (TIME SET)

D. Do you intend to take your own life? (INTENTION)

E. Level of Suicide Risk

1) Low -Some suicidal thoughts. No suicide plan. Says he or she won't attempt suicide.

2) Moderate - Suicidal thoughts. Vague plan that isn’t very lethal. Says he or she won’t attempt suicide.

3) High - Suicidal thoughts. Specific plan that is highly lethal. Says he or she won't attempt suicide.

4) Severe - Suicidal thoughts. Specific plan that is highly lethal. Says he or she will attempt suicide.

If a suicide attempt seems imminent, call a local crisis center, dial, or take the person to an emergency room. Remove guns, drugs, knives, and other potentially lethal objects from the vicinity but do not, under any circumstances, leave a suicidal person alone [29,30].

Offer help and support

If a friend or family member is suicidal, the best way to help is by offering an empathetic, listening ear. Let your loved one know that he or she is not alone and that you care. Don’t take responsibility, however, for making your loved one well. You can offer support, but you can't get better for a suicidal person. He or she has to make a personal commitment to recovery [31].

It takes a lot of courage to help someone who is suicidal. Witnessing a loved one dealing with thoughts about ending his or her own life can stir up many difficult emotions. As you’re helping a suicidal person, don't forget to take care of yourself. Find someone that you trust-a friend, family member, clergyman, or counsellor-to talk to about your feelings and get support of your own [32].

Helping a suicidal person

Get professional help: Do everything in your power to get a suicidal person the help he or she needs. Call a crisis line for advice and referrals. Encourage the person to see a mental health professional, help locate a treatment facility, or take them to a doctor’s appointment.

Follow-up on treatment: If the doctor prescribes medication, make sure your friend or loved one takes it as directed. Be aware of possible side effects and be sure to notify the physician if the person seems to be getting worse. It often takes time and persistence to find the medication or therapy that's right for a particular person [33].

Be proactive. Those contemplating suicide often don’t believe they can be helped, so you may have to be more proactive at offering assistance. Saying, "Call me if you need anything” is too vague. Don't wait for the person to call you or even to return your calls. Drop by, call again, invite the person out. Encourage positive lifestyle changes, such as a healthy diet, plenty of sleep, and getting out in the sun or into nature for at least 30 minutes each day. Exercise is also extremely important as it releases endorphins, relieves stress, and promotes emotional well-being.

Make a safety plan. Help the person develop a set of steps he or she promises to follow during a suicidal crisis. It should identify any triggers that may lead to a suicidal crisis, such as an anniversary of a loss, alcohol, or stress from relationships. Also include contact numbers for the person's doctor or therapist, as well as friends and family members who will help in an emergency.

Remove potential means of suicide, such as pills, knives, razors, or firearms: If the person is likely to take an overdose, keep medications locked away or give out only as the person needs them.

Continue your support over the long haul. Even after the immediate suicidal crisis has passed, stay in touch with the person, periodically checking in or dropping by. Your support is vital to ensure your friend or loved one remains on the recovery track [34].

At least 90 percent of all people who die by suicide suffer from one or more mental disorders such as depression, bipolar disorder, schizophrenia, or alcoholism. Depression in particular plays a large role in suicide. The difficulty suicidal people have imagining a solution to their suffering is due in part to the distorted thinking caused by depression [35].

Common suicide risk factors include

A. Mental illness, alcoholism or drug abuse

B. Previous suicide attempts, family history of suicide, or history of trauma or abuse

C. Terminal illness or chronic pain, a recent loss or stressful life event

D. Social isolation and loneliness

E. Antidepressants and suicide

For some, depression medication causes an increase-rather than a decrease-in depression and suicidal thoughts and feelings. Because of this risk, the FDA advises that anyone on antidepressants should be watched for increases in suicidal thoughts and behaviors. Monitoring is especially important if this is the person's first time on depression medication or if the dose has recently been changed. The risk of suicide is the greatest during the first two months of antidepressant treatment [36-38].

Suicide in teens and older adults

In addition to the general risk factors for suicide, both teenagers and older adults are at a higher risk of suicide.

Suicide in teens

Teenage suicide is a serious and growing problem. The teenage years can be emotionally turbulent and stressful. Teenagers face pressures to succeed and fit in. They may struggle with self-esteem issues, self-doubt, and feelings of alienation. For some, this leads to suicide. Depression is also a major risk factor for teen suicide [39].

Other risk factors for teenage suicide include

1. Childhood abuse

2. Recent traumatic event

3. Lack of a support network

4. Availability of a gun

5. Hostile social or school environment

6. Exposure to other teen suicides

Additional warning signs that a teen may be considering

suicide

A. Change in eating and sleeping habits

B. Withdrawal from friends, family, and regular activities

C. Violent or rebellious behavior, running away

D. Drug and alcohol use

E. Unusual neglect of personal appearance

F. Persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork

G. Frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc.

H. Not tolerating praise or rewards

Suicide in the elderly

The highest suicide rates of any age group occur among persons aged 65 years and older. One contributing factor is depression in the elderly that is undiagnosed and untreated.

Other risk factors for suicide in the elderly include

A. Recent death of a loved one, isolation and loneliness

B. Physical illness, disability, or pain

C. Major life changes, such as retirement or loss of independence

D. Loss of sense of purpose

E. Warning signs in older adults

Additional warning signs that an elderly person may be contemplating suicide

A. Reading material about death and suicide

B. Disruption of sleep patterns

C. Increased alcohol or prescription drug use

D. Failure to take care of self or follow medical orders

E. Stockpiling medications or sudden interest in firearms

F. Social withdrawal, elaborate good-byes, rush to complete or revise a will

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