Suicide prevention

The examples and perspective in this article deal

primarily with the United States and do not
Learn more

As a suicide prevention initiative, this sign on the

Golden Gate Bridge promotes a special telephone,
available on the bridge itself, with which persons
considering suicide can connect to a crisis hotline.
Suicide prevention, as an umbrella term,
involves the collective efforts of local
citizen organizations, of health
professionals and of related professionals
to reduce the incidence of suicide. Beyond
direct interventions to stop an impending
suicide, methods may also involve:

treating the psychological and

psychophysiological symptoms of
depression
improving the coping strategies of
persons who might otherwise seriously
consider suicide
reducing the prevalence of conditions
believed to constitute risk factors for
 suicide, such as poverty or anomie
giving people hope for a better life after
current problems are resolved

General efforts have included preventive

and proactive measures within the realms
of medicine and mental health, as well as
public health and other fields. Because
protective factors[1] such as social support
and social engagement — as well as
environmental risk-factors such as access
to lethal means — apparently play
significant roles in suicide prevention, one
cannot view suicide solely as either a
medical issue or as a mental-health
issue.[2] Suicide prevention is risky for
health professionals in terms of
practitioners' emotional distress and the
possibility of malpractice suits.[3]

Risk assessment
Warning signs

Being aware of the warning signs of

suicide can allow individuals to direct
people who may be considering suicide to
get help.[4]

Warning

1. Suicidal ideation: thinking, talking, or

writing about suicide, planning for
 suicide
2. Substance abuse
3. Purposelessness
4. Anxiety, agitation and unable to sleep or
not sleeping all the time
5. Trapped
6. Hopelessness
7. Social withdrawal from friends, family, or
society
8. Anger, rage or seeking revenge
9. Recklessness or impulsiveness
10. Mood changes including depression
11. Uselessness
Additionally, the national institute for
mental health includes feeling
burdonsome, and strong feelings of pain--
either emotional or physical--as warning
signs that someone may intend attempt
suicide.[4]

Some signs that someone may attempt

suicide include:[4]

1. strong feelings of pain, either emotional

or physical considering oneself
burdensome
2. increased use of drugs or alcohol

Screening
The U.S. Surgeon General has suggested
that screening to detect those at risk of
suicide may be one of the most effective
means of preventing suicide in children
and adolescents.[5] There are various
screening tools in the form of self-report
questionnaires to help identify those at
risk such as the Beck Hopelessness Scale
and Is Path Warm?. A number of these
self-report questionnaires have been
tested and found to be effective for use
among adolescents and young adults.[6]
There is however a high rate of false-
positive identification and those deemed
to be at risk should ideally have a follow-
up clinical interview.[7] The predictive
quality of these screening questionnaires
has not been conclusively validated so it is
not possible to determine if those
identified at risk of suicide will actually
commit suicide.[8] Asking about or
screening for suicide does not create or
increase the risk.[9]

In approximately 75 percent of completed

suicides, the individuals had seen a
physician within the year before their
death, including 45 to 66 percent within
the prior month. Approximately 33 to 41
percent of those who completed suicide
had contact with mental health services in
the prior year, including 20 percent within
the prior month. These studies suggest an
increased need for effective
screening.[10][11][12][13][14] Many suicide risk
assessment measures are not sufficiently
validated, and do not include all three core
suicidality attributes (i.e., suicidal affect,
behavior, and cognition).[15] A study
published by the University of New South
Wales has concluded that asking about
suicidal thoughts cannot be used as a
reliable predictor of suicide risk.[16]

Underlying condition

The conservative estimate is that 10% of

individuals with psychiatric disorders may
have an undiagnosed medical condition
causing their symptoms,[17] upwards of
50% may have an undiagnosed medical
condition which if not causing is
exacerbating their psychiatric
symptoms.[18][19] Illegal drugs and
prescribed medications may also produce
psychiatric symptoms.[20] Effective
diagnosis and if necessary medical testing
which may include neuroimaging[21] to
diagnose and treat any such medical
conditions or medication side effects may
reduce the risk of suicidal ideation as a
result of psychiatric symptoms, most
often including depression, which are
present in up to 90–95% of cases.[22]
Interventions

A photo illustration produced by the Defense Media

Agency on suicide prevention

Many methods have been developed in an

effort to prevent suicide. The general
methods include: direct talks, screening
for risks, lethal means reduction and social
intervention. The medication lithium may
be useful in certain situations to reduce
the risk of suicide.[23][24] Talk therapies[25]
including phone delivery of services may
also help.[26]

Direct talks

National Suicide Prevention Lifeline, a nationwide

crisis line in the United States also available in Canada

An effective way to assess suicidal

thoughts is to talk with the person directly,
to ask about depression, and assess
suicide plans as to how and when it might
be attempted.[27] Contrary to popular
misconceptions, talking with people about
suicide does not plant the idea in their
heads.[27] However, such discussions and
questions should be asked with care,
concern and compassion.[27] The tactic is
to reduce sadness and provide assurance
that other people care. The WHO advises
to not say everything will be all right nor
make the problem seem trivial, nor give
false assurances about serious issues.[27]
The discussions should be gradual and
specifically executed when the person is
comfortable about discussing his or her
feelings. ICARE (Identify the thought,
Connect with it, Assess evidences for it,
Restructure the thought in positive light,
Express or provide room for expressing
feelings from the restructured thought) is
a model of approach used here.[27][28]

Lethal means reduction

Means reduction, reducing the odds that a

suicide attempter will use highly lethal
means, is an important component of
suicide prevention.[29] This practice is also
called "means restriction".

Researchers and health policy planners

have theorized and demonstrated that
restricting lethal means can help reduce
suicide rates, as delaying action until
depression passes.[30] In general, strong
evidence supports the effectiveness of
means restriction in preventing
suicides.[31] There is also strong evidence
that restricted access at so-called suicide
hotspots, such as bridges and cliffs,
reduces suicides, whereas other
interventions such as placing signs or
increasing surveillance at these sites
appears less effective.[32] One of the most
famous historical examples, of means
reduction, is that of coal gas in the United
Kingdom. Until the 1950s, the most
common means of suicide in the UK was
poisoning by gas inhalation. In 1958,
natural gas (virtually free of carbon
monoxide) was introduced, and over the
next decade, comprised over 50% of gas
used. As carbon monoxide in gas
decreased, suicides also decreased. The
decrease was driven entirely by dramatic
decreases in the number of suicides by
carbon monoxide poisoning.[33][34]

In the United States, numerous studies

have concluded that firearm access is
associated with increased suicide
completion.[35] "About 85% of attempts
with a firearm are fatal: that's a much
higher case fatality rate than for nearly
every other method. Many of the most
widely used suicide attempt methods have
case fatality rates below 5%."[36][37]
Although restrictions on access to
firearms have reduced firearm suicide
rates in other countries, such restrictions
are not feasible in the United States
because the Second Amendment to the
United States Constitution guarantees the
right to own firearms, prohibiting large
scale restrictions on weapons.[38]

Social intervention
A telephone connected to a crisis hotline at Niagara
Falls State Park

National Strategy for Suicide Prevention

promotes and sponsors various specific
suicide prevention endeavors:

Developing groups led by professionally

trained individuals for broad-based
support for suicide prevention.
Promoting community-based suicide
prevention programs.
Screening and reducing at-risk behavior
through psychological resilience
programs that promotes optimism and
connectedness.
Education about suicide, including risk
factors, warning signs, stigma related
issues and the availability of help
through social campaigns.
Increasing the proficiency of health and
welfare services at responding to people
in need. e.g., Sponsored training for
helping professionals, Increased access
to community linkages, employing crisis
counseling organizations.
Reducing domestic violence and
substance abuse through legal and
empowerment means are long-term
strategies.
Reducing access to convenient means
of suicide and methods of self-harm.
e.g., toxic substances, poisons,
handguns.
Reducing the quantity of dosages
supplied in packages of non-prescription
medicines e.g., aspirin.
School-based competency promoting
and skill enhancing programs.
 Interventions and usage of ethical
surveillance systems targeted at high-
risk groups.
Improving reporting and portrayals of
negative behavior, suicidal behavior,
mental illness and substance abuse in
the entertainment and news media.
Research on protective factors &
development of effective clinical and
professional practices.

It has also been suggested by NSSP that

media should prevent romanticising of
negative emotions and coping strategies
which can lead to vicarious traumatization.
The Centers for Disease Control and
Prevention (from a 1994 workshop) and
the American Foundation for Suicide
Prevention (1999) have suggested that TV
shows and news media can help prevent
suicide by linking suicide with negative
outcomes such as pain for the suicide and
their survivors, conveying that the majority
of people choose something other than
suicide in order to solve their problems,
avoiding mentioning suicide epidemics,
and avoiding presenting authorities or
sympathetic, ordinary people as
spokespersons for the reasonableness of
suicide.[39]

Postvention
Postvention is for people affected by an
individual's suicide, this intervention
facilitates grieving, guides to reduce guilt,
anxiety, and depression and to decrease
the effects of trauma. Bereavement is
ruled out and promoted for catharsis and
supporting their adaptive capacities before
intervening depression and any psychiatric
disorders. Postvention is also provided to
intervene to minimize the risk of imitative
or copycat suicides, but there is a lack of
evidence based standard protocol. But the
general goal of the mental health
practitioner is to decrease the likelihood of
others identifying with the suicidal
behavior of the deceased as a coping
strategy in dealing with adversity.[40]

Medication

Recent research has shown that lithium

has been effective with lowering the risk of
suicide in those with bipolar disorder to
the same levels as the general
population.[41] Lithium has also proven
effective in lowering the suicide risk in
those with unipolar depression as well.[42]

Counseling

There are multiple evidence-based

psychotherapeutic talk therapies available
to reduce suicidal ideation such as
dialectical behavior therapy (DBT) for
which multiple studies have reported
varying degrees of clinical effectiveness in
reducing suicidality. Benefits include a
reduction in self-harm behaviours and
suicidal ideations.[43][44] Cognitive
Behavior Therapy for Suicide Prevention
(CBT-SP) is a form of DBT adapted for
adolescents at high risk for repeated
suicide attempts.[45][46]

The World Health Organization

recommends "specific skills should be
available in the education system to
prevent bullying and violence in and
around the school premises in order to
create a safe environment free of
intolerance".[47]

Coping planning

Coping planning is an innovative

strengths-based intervention that aims to
meet the needs of people who ask for
help, including those experiencing suicidal
ideation.[48] By addressing why someone
asks for help, the risk assessment and
management stays on what the person
needs, and the needs assessment focuses
on the individual needs of each
person.[49][50] The Coping Planning
approach to suicide prevention draws on
the health-focused theory of coping.
Coping is normalized as a normal and
universal human response to unpleasant
emotions and interventions are considered
a change continuum of low intensity (e.g.
self-soothing) to high intensity support
(e.g. professional help). By planning for
coping, it supports people who are
distressed and provides a sense of
belongingness and resilience in treatment
of illness.[51][52] The proactive coping
planning approach overcomes
implications of ironic process
theory.[53]The biopsychosocial[54] strategy
of training people in healthy coping
improves emotional regulation and
decreases memories of unpleasant
emotions.[55] A good coping planning
strategically reduces the inattentional
blindness for a person while developing
resilience and regulation strengths.[56]

Support groups

Many non-profit organizations exist, such

as the American Foundation for Suicide
Prevention in the United States, which
serve as crisis hotlines; it has benefited
from at least one crowd-sourced
campaign.[57] The first documented
program aimed at preventing suicide was
initiated in 1906 in both New York, the
National Save-A-Life League and in
London, the Suicide Prevention
Department of the Salvation Army.[58]

Suicide prevention interventions fall into

two broad categories: prevention targeted
at the level of the individual and prevention
targeted at the level of the population.[59]
To identify, review, and disseminate
information about best practices to
address specific objectives of the National
Strategy Best Practices Registry (BPR)
was initiated. The Best Practices Registry
of Suicide Prevention Resource Center is a
registry of various suicide intervention
programs maintained by the American
Association of Suicide Prevention. The
programs are divided, with those in
Section I listing evidence-based programs:
interventions which have been subjected
to indepth review and for which evidence
has demonstrated positive outcomes.
Section III programs have been subjected
to review.[60][61]

Model of suicide
Van Orden et al. (2010) posited that there
are two major factors involved in suicide
attempts. The first major factor is a desire
for death and the second acquired
capability. Desire for death occurs through
ideations of thwarted belongingness. It is
described as feeling alienated from others
emotionally and perceived
burdensomeness which is described as
feeling that one is incompetent and
therefore a burden on others.[62] The
acquired capability in this context is used
because people naturally fear death and
painful experiences. The capability to carry
out the suicide attempt is usually formed
from emotional and physical pain and
disrupted cognitive status and is acquired
through previous suicide attempts (self-
directed violence), rehearsing suicide
through behavior or imagery, and getting
used to painful or dangerous experiences
in other ways.

Individuals who are suicidal often have

tunnel vision about the situation and
consider permanence of suicide as an
easy way out of a difficult situation.[63]
Other significant risk factors for suicide
include psychiatric disorders, substance
abuse, etc.[64][65] Individuals who have
good interpersonal social relationship and
family support tend to have lower risk of
suicide.[66] People who have greater self-
control, greater self-efficacy, intact reality-
testing, and more adaptive coping skills
are at less risk. Those who are hopeful,
have future plans or events to look forward
to, and have satisfaction in life are
considered to have protective factors
against suicide.[67]

Strategies

A United States Army suicide prevention poster

Suicide is the act of deliberately killing

oneself or, more specifically, an act
deliberately initiated and performed by the
person concerned in the full knowledge, or
expectation, of its fatal outcome.[68]

In recognition of the need for

comprehensive approaches to suicide
prevention, various strategies have been
developed with the support of evidence.
The traditional approach has been to
identify the risk factors that increase
suicide or self-harm, though meta-analysis
studies suggest that suicide risk
assessment might not be useful and
recommend immediate hospitalization of
the person with suicidal feelings as the
healthy choice.[69] In 2001, the U.S.
Department of Health and Human
Services, under the direction of the
Surgeon General, published the National
Strategy for Suicide Prevention,
establishing a framework for suicide
prevention in the U.S. The document calls
for a public health approach to suicide
prevention, focusing on identifying
patterns of suicide and suicidal ideation
throughout a group or population (as
opposed to exploring the history and
health conditions that could lead to
suicide in a single individual).[70] The
ability to recognize warning signs of
suicide allows individuals who may be
concerned about someone they know to
direct them to help.[4]
Suicide gesture and suicidal desire (a
vague wish for death without any actual
intent to kill oneself) are potentially self-
injurious behaviors that a person may use
to attain some other ends, like to seek
help, punish others, or to receive attention.
This behavior has the potential to aid an
individual’s capability for suicide and can
be considered as a suicide warning, when
the person shows intent through verbal
and behavioral signs.[71]

Specific strategies

Suicide prevention strategies focus on

reducing the risk factors and intervening
strategically to reduce the level of risk.
Risk and protective factors, unique to the
individual can be assessed by a qualified
mental health professional.

Some of the specific strategies used to

address are:

Crisis intervention.
Structured counseling and
psychotherapy.
Hospitalization for those with low
adherence to collaboration for help and
those who require monitoring &
secondary symptom treatment.
Supportive therapy like substance abuse
treatment, Psychotropic medication,
Family psychoeducation and Access to
emergency phone call care with
emergency rooms, suicide prevention
hotlines...etc.
Restricting access to lethality of suicide
means through policies and laws.
Creating & using crisis cards, an
uncluttered card formatted readably that
describes a list of activities one should
follow in crisis until the positive behavior
responses settles in the personality.
Person-centered life skills training. e.g.,
Problem solving.
 Registering with support groups like
Alcoholics Anonymous, Suicide
Bereavement Support Group, a religious
group with flow rituals, etc.
Therapeutic recreational therapy that
improves mood.
Motivating self-care activities like
physical exercise's and meditative
relaxation.

Psychotherapies that have shown most

successful or evidence based are
Dialectical behavior therapy (DBT), it has
shown to be helpful in reducing suicide
attempts and reducing hospitalizations for
suicidal ideation[72] and Cognitive therapy
(CBT), it has shown to improve problem-
solving and coping abilities.[73]

Preventative Factors

Individuals with access to proper mental

health care, a sense of belonging, good
problem solving skills, and a system of
beliefs that discourages suicide are less
likely to attempt suicide.[74]

Economics
In the United States it is estimated that an
episode of suicide results in costs of
about $1.3 million. Money spending on
appropriated interventions is estimated to
result in a decrease in economic loses that
are 2.5 fold greater than the amount
spent.[75]

See also
Advocacy of suicide
Coping (psychology)
Coping Planning
Crisis intervention
Euthanasia
Gatekeeping (education)
List of suicide crisis lines
Living Is For Everyone
Social skills
 Suicide prevention contract
World Suicide Prevention Day

Suicide prevention organizations

American Foundation for Suicide

Prevention
Campaign Against Living Miserably
International Association for Suicide
Prevention
National Suicide Prevention Lifeline
Samaritans (charity)
SOSAD Ireland
Suicide Prevention Australia
Suicide Prevention Action Network USA
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Further reading
Suicide prevention and assessment
handbook , Centre for Addiction and
Mental Health, 2011.
Nancy Boyd-Franklin; Elizabeth N. Cleek;
Matt Wofsy; Brian Mundy (2013). "Risk
 Assessment and Suicide Prevention".
Therapy in the Real World: Effective
Treatments for Challenging Problems .
Guilford Press. p. 341. ISBN 978-1-4625-
1034-4.
Van Orden K. A.; et al. (2010). "The
interpersonal theory of suicide".
Psychological Review. 117: 575–600.
doi:10.1037/a0018697 .

External links
CDC website on Suicide Prevention
The Suicide Prevention Resource Center
(SPRC) provides prevention support,
training, and resources to assist
organizations and individuals to develop
suicide prevention programs,
interventions and policies, and to
advance the National Strategy for
Suicide Prevention.
Centre for Suicide Prevention (CSP),
Canada
Suicide Prevention:Effectiveness and
Evaluation A 32-page guide from SPAN
USA, the National Center for Injury
Prevention and Control, and Education
Development Center, Inc.
International Association for Suicide
Prevention Organization co-sponsors
World Suicide Prevention Day on
 September 10 every year with the World
Health Organization (WHO).
U.S. Surgeon General - Suicide
Prevention
Suicide Risk Assessment Guide - VA
Reference Manual
Self-harm care management, NICE, UK
Practice Guidelines for Suicide
prevention, APA

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