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Suicide and Risk Assessment Back to Course Index



Suicide occurs when the pain exceeds the
          Resources for Coping


Two thousand people die each day throughout the world from self-inflicted means.  That constitutes 80 people an hour.  By the time you complete this course, 320 fathers, mothers, sons, daughters, or neighbors will have ended their life.  I am reminded of what an ICU nurse said to me one evening as I was on the unit to asses a patient who had attempted suicide, I just don’t know what to do with how I feel.  I have three patients tonight two desperately trying to live that most likely won’t survive the next week and one previously perfectly healthy 32-year-old father of two that tried to kill himself.




In the United States, more than 29,000 people die by suicide every year. It is this country’s 11th leading cause of death.  Suicide is the 2nd leading cause of death among college students.  It is the 3rd leading cause of death among 15-24-year-olds.  The population, most at risk for suicide, is the elderly. 


There are approximately four males who complete suicide for every female. However, twice as many females make an attempt.  There are an estimated eight to twenty-five attempted suicides to one completion.


These statistics are believed to be grossly underestimated due to under-reporting.  The reasons for under-reporting include:

(1) Families or family physicians may hide evidence due to the stigma of suicide.  Often families feel ashamed and guilty.  Parents feel like failures.  The physicians want to spare additional family pain.

(2) The determination of cause-of-death is made by local standards, which vary widely. The local police who are first on the scene, the coroner, the district attorney, they each have individual criteria by which they are evaluating a death. 

(3) Many deaths are ambiguous and are classified as “accidental” or “undetermined”. 

(4) Families may hide evidence due to clauses in much-needed life insurance policies.

 In opposition to the under-reporting issue, undoubtedly, there are deaths that are classified as suicides that are more likely accidental deaths or murder.  These usually occur in prisons, hospitals, religious orders, and the military. 

In the case of homicide, investigations are lengthy and difficult, and accidents may be the basis of negligence lawsuits; far easier when ambiguity exists to opt for the determination of suicide. 

All of this represents what society accepts as suicidal intent, but what of refusing medical treatment in terminal illness, for religious reasons or martyrdom?  Should we include high-speed drag racing and drunk driving deaths in the statistics?  As Geo Stone notes, If you play Russian roulette with a six-shooter, your odds of dying are one in six; if you climb Mt. Everest, they’re also about one in six. The former is a generally-condemned form of suicide; what, then, is the latter?

With all of the statistics in place, think of it this way:  you are more likely to kill yourself than be killed by someone else.


The Choice of Suicide

There are three necessary and sufficient conditions for a suicidal event to occur:


1) There must be sufficient psychological pain.


2) The wish to die must be greater than the wish to live.


3) A self-injury method must be available.

Let’s look at each of these individually.



Psychological Pain

  • Current/Acute suicidal thoughts and/or intent
  • History of mental illness
  • The intensity of current depressive symptoms
  • Current treatment regimen and response
  •  Recent life stressors (separation, loss)
  • Alcohol and drug use patterns
  • Psychotic symptoms
  • Current living situation (support system)

Thousands of theorists have tried to answer the question of why people kill themselves.  Geo Stone, Suicide and Attempted Suicide summarize the reasons best in three words: to stop pain.

Psychological pain can include a myriad of issues.  Although most depressed people are not suicidal, most suicidal people are depressed. Depression, stress, and grief can be suffocating.  It can seem as though there is no viable way out of the problems, short of escaping into death.  Even more unnerving are the statistics that show those who cannot differentiate between long-term problems and situational problems.  A suicide in response to the long term, the chronic problem is distressing.  A suicide in response to a single event such as failing a test or not making the team is heartbreaking.


The Wish To Die Must Be Greater Than The Wish To Live

All behavior has a positive intention.  Not all behavior is positive, but on some level, the desired outcome has a positive motive.  When assessing the potential for suicide in a patient, it is difficult to ascertain their level of commitment.  An understanding of where a patient is coming from is necessary to understand what positive intention their behavior has.  One night a ship’s captain saw the lights of what he thought was an approaching ship heading directly toward the vessel he was commanding.  He ordered his communications officer to blink a message to the approaching ship:  Change your course 10 degrees south.  A reply came back instantly. Change your course 10 degrees north.  The captain fired back, I’m a captain, change your course south.  Another reply came back quickly. Well, I’m a seaman 1st class, change your course north.  Infuriated, the ship’s captain signaled back sharply, Dammit, I’ll say one last time, change your course south. I’m on a battleship!  The immediate volley came back, and I say change your course north; I’m in a lighthouse. (author unknown). You have to determine where the person is emotionally to make an assessment of how safe they are.  What is a challenge to one person is unbearable to another. 


All gestures and attempts are serious.  Some of the issues to take into account in determining how much should be done to ensure someone’s safety include looking at whether they have made previous attempts, how lethal were those attempts and is the attempt a means to simply end life or change it somehow.  An emotional pay off does not make the behavior less dangerous or the attempt less serious, but there would other avenues in treatment that should be addressed.  


As a mental health counselor in the psychiatric hospital setting, I assessed several hundred suicide attempts.  I clearly remember only two individuals who wanted to die over any other possible solution.  Those who are serious about suicide are not attention-seeking, however there an unfortunate many that do use behavior to manipulate when they are void of other productive means.  Suicides can also occur as a person in need continues to up the ante with high-risk behaviors

Ann and John have had a rocky relationship for years. John seems to spend more and more time at the local bar hanging out with his friends. Ann has tried to talk with him about how lonely she gets when he is away all of the time, but he just complains that she is nagging. Ann ingests 10 Tylenol then calls 911. John rushes to the E.R., and things improve between them for several weeks. Over time John feels safe, leaving Ann and actually begins to resent having to babysit her emotions. He begins to go out with the guys too often again. They fight frequently, Ann leaves him several times, just to reconcile days later. After a particularly bad fight, John storms out of the house. He yells back at Ann for her not to wait up for him, as he has no intention of coming home until he is ready. Ann then takes 15 Tylenol and makes a superficial cut on her wrist as this cycle continues; these behaviors can result in an accidental suicide.


Method Availability

It is worthy of repeating, all statements, gestures, and attempts are serious.  In addition to this, it is a professionals goal to help a client in the lowest level of care necessary.  When making that determination, a factor that can give detail to where a client is at in the ideation of suicide is to ask if they have thought of killing themselves, and if so, how.  If the response is that they have thought about dying by shooting themselves and they do not have access to a gun, the situation is less threatening in the immediate than someone who plans on taking the readily available prescription drugs waiting in the bathroom.  At least, there is the potential for intervention time.


As noted by the American Foundation for Suicide, the factors that contribute to any particular suicide are diverse and complex, so our efforts to understand it must incorporate many approaches. The clinical, neurobiological, legal, and psychosocial aspects of suicide are some of the major lines of inquiry into suicide.


Who Is at Risk for Suicide?

Suicide does not discriminate. People of all genders, ages, and ethnicities can be at risk.


  • A prior suicide attempt
  • Depression and other mental health disorders
  • Substance abuse disorder
  • Family history of a mental health or substance abuse disorder
  • Family history of suicide
  • Family violence, including physical or sexual abuse
  • Having guns or other firearms in the home
  • Being in prison or jail
  • Being exposed to others’ suicidal behavior, such as a family member, peer, or media figure
  • Medical illness
  • Being between the ages of 15 and 24 years or over age 60 

Even among people who have risk factors for suicide, most do not attempt suicide. It remains difficult to predict who will act on suicidal thoughts.

As mentioned earlier, according to the Centers for Disease Control and Prevention (CDC), men are more likely to die by suicide than women, but women are more likely to attempt suicide. Men are more likely to use more lethal methods, such as firearms or suffocation. Women are more likely than men to attempt suicide by poisoning.

Also, per the CDC, certain demographic subgroups are at higher risk. For example, American Indian and Alaska Native youth and middle-aged persons have the highest rate of suicide, followed by non-Hispanic White middle-aged and older adult males. African Americans have the lowest suicide rate, while Hispanics have the second-lowest rate. The exception to this is younger children. African American children under the age of 12 have a higher rate of suicide than White children. While younger preteens and teens have a lower rate of suicide than older adolescents, there has been a significant rise in the suicide rate among youth ages 10 to 14. Suicide ranks as the second leading cause of death for this age group, accounting for 425 deaths per year and surpassing the death rate for traffic accidents, which is the most common cause of death for young people.


Overall the most common risk factors to address in a risk assessment include:

  • History of Suicide Attempts
  • Medical Seriousness of Previous Attempts
  • Acute Suicidal Ideation
  • Family History of Suicide
  •  Acute Overuse of Alcohol and or Other Drugs

       –Alcoholism is a factor in about 30% of all completed suicides.
       -Approximately 7 percent of those with alcohol dependence will die by suicide.

  • Loss/Separations

SAD PERSONS: a mnemonic for assessing suicide risk

S ex (male)

A ge (elderly or adolescent)

D epression


P revious suicide attempts

E thanol abuse

R ational thinking (psychosis)

S ocial supports lacking

O rganized plan

N o spouse (divorced, widowed, single)

S ickness (physical illness)


Other considerations noted by the American Foundation for Suicide  include:

Intense Affective State in Addition to Depression
Immediate relief is sought.  The individual expresses desperation, rage, anxiety, guilt, hopelessness, or an acute sense of abandonment.

Changes in Behavior and Speech
Be alert to such statements as “my children would be better off with a happy mommy.” Or “my parents would be happier if they didn’t have me to deal with.” Often those contemplating suicide talk as if they are saying signing off or going away. 


Deterioration in the level of functioning  
Work or schoolwork declines, increasing the use of alcohol, other self-destructive behavior, loss of control, rage explosions.


Initial Management and Disposition

There are many intervention strategies for professionals and loved ones to access to help those in need. 

When assessing a client for suicide risk, it is helpful to categorize them into one of three categories:

Ideation, Plan, and Intent
Hospitalization is necessary, especially if they have current determination of what is necessary.

Ideation, Plan, No Intent
In some circumstances, these clients can be treated in outpatient settings, especially if they have a solid support system and no access to lethal means.  In some cases, hospitalization is necessary.

Ideation, No Plan, No Intent
These clients should be evaluated carefully for psychosocial stressors.  With a good support system in place an no lethal means, they can generally be treated in outpatient.

Most people who have risk factors for suicide will not kill themselves. However, the risk for suicidal behavior is complex. Research suggests that people who attempt suicide may react to events, think, and make decisions differently than those who do not attempt suicide. These differences happen more often if a person also has a disorder such as depression, substance abuse, anxiety, borderline personality disorder, and psychosis. Risk factors are important to keep in mind; however, someone who has warning signs of suicide may be in more danger and require immediate attention.


What Are the Warning Signs of Suicide?

The behaviors listed below may be signs that someone is thinking about suicide.

  • Talking about wanting to die or wanting to kill themselves

  • Talking about feeling empty, hopeless, or having no reason to live

  • Planning or looking for a way to kill themselves, such as searching online, stockpiling pills, or newly acquiring potentially lethal items (e.g., firearms, ropes)

  • Talking about great guilt or shame

  • Talking about feeling trapped or feeling that there are no solutions

  • Feeling unbearable pain, both physical or emotional

  • Talking about being a burden to others

  • Using alcohol or drugs more often

  • Acting anxious or agitated

  • Withdrawing from family and friends

  • Changing eating and/or sleeping habits

  • Showing rage or talking about seeking revenge

  • Taking risks that could lead to death, such as reckless driving

  • Talking or thinking about death often

  • Displaying extreme mood swings, suddenly changing from very sad to very calm or happy

  • Giving away important possessions

  • Saying goodbye to friends and family

  • Putting affairs in order, making a will


Suicide Crisis Calls

A suicidal patient may evoke significant strong emotions in a counselor, such as anger toward the client or fear of losing the client, of personal failure or professional consequences in preventing attempts.  However, despite these emotions, mental health professionals can have a tremendous impact by arming themselves with the knowledge and skill to successfully treat depressed clients and prevent suicide.  

David L. Conroy, Ph.D., makes the following recommendations for how to handle a caller who is suicidal.

1. Be yourself. The right words are unimportant. If you are concerned, your voice and manner will show it.

2. Listen. Let the person unload despair, ventilate anger. If given an opportunity to do this, he or she will feel better by the end of the call. No matter how negative the call seems, the fact that it exists is a positive sign, a cry for help.

3. Be sympathetic, non-judgmental, patient, calm, accepting. The caller has done the right thing by getting in touch with another person.

4. If the caller is saying I’m so depressed, I cannot go on, ask The Question: Are you having thoughts of suicide?

5. If the answer is yes, you can begin asking a series of further questions: Have you thought about how you would do it (PLAN); Have you got what you need (MEANS); Have you thought about when you would do it (TIME SET). 95% of all suicidal callers will answer no at some point in this series or indicate that the time is set for some date in the future. This will be a relief for both of you.

6. Simply talking about their problems for a length of time will give suicidal people relief from loneliness and pent up feelings, the awareness that another person cares, and a feeling of being understood. They also get tired — their body chemistry changes. These things take the edge off their agitated state and help them get through a bad night.

7. Avoid arguments, problem-solving, advice-giving, quick referrals, belittling, and making the caller feel that has to justify his suicidal feelings. It is not how bad the problem is, but how badly it is hurting the person who has it.

8. If the person is ingesting drugs, get the details (what, how much, alcohol, other medications, last meal, general health) and call Poison Control or 911.  A shift partner can call while you continue to talk to the person, or you can get the caller’s permission and do it yourself on another phone while the caller listens to your side of the conversation. If Poison Control recommends immediate medical assistance, ask if the caller has a nearby relative, friend, or neighbor who can assist with transportation or the ambulance. In a few cases, the person will initially refuse needed medical assistance. Remember that the call is still a cry for help and stay with him in a sympathetic and non-judgmental way. Ask for his address and phone number in case he changes his mind. (Call the number to make sure it’s busy.) If your organization does not trace calls, be sure to tell him that.

9. Do not go it alone. Get help during the call and debrief afterwards.

10. Your caller may be concerned about someone else who is suicidal. Just listen, reassure him that he or she is doing the right thing by taking the situation seriously, and sympathize with the stressful situation. With some support, many third parties will work out reasonable courses of action on their own. In the rare case where the third party is really a first-party, just listening will enable you to move toward his or her problems. You can ask, “Have you ever been in a situation where you had thoughts of suicide?


In Conclusion

Suicide, in most cases, can be prevented. While some suicides occur without any precedence, most do not. The most effective way to prevent suicide is to learn how to recognize the signs of someone at risk, take those signs seriously, and know how to respond to them.

Many of the catalysts for suicide are temporary; suicide is permanent.  Suicide is not a random or senseless act, but an unchangeable, extreme solution.