This section recognizes special issues in suicide assessment and intervention, including age, hospitalization, and the perinatal period. It also addresses the heightened risk of suicide among certain professions, such as military personnel and healthcare workers. The section concludes with a list of resources that clinicians may find helpful when dealing with suicidal patients.
Children, Adolescents, and Young Adults
Over the past decade, there has also been a 57.4% increase in the rate of suicide among U.S. youth aged 10-24. According to a recent CDC report, there are now 10.7 suicides/100,000 persons in this age group, compared to 6.8/100,000 in 2007 (Curtin, 2020). While suicides among 5- to 11-year-olds are rare, they have also increased significantly between 2009 and 2018 (Sheftall et al., 2016).
The increase in suicide among youth has been propelled by an increase in firearm suicides in the 10- to 24-year age range, and particularly in the 10- to 14-year age range.
Over the past decade, there has been a 56% rise in the rate of firearm suicides among 10- to 24-year-olds, and a staggering 213% rise of firearm suicides among 10- to 14-year-olds (CDC WISQARS, n.d.; Everytown Research & Policy, 2020). American Indian and Alaska Native youth have the highest firearm suicide rate among their age group, followed by white and Black youth (Everytown Research & Policy, 2020).
At the 2020 National Stop A Suicide Today Town Hall, Dr. Tami Benton, Executive Director and Chair of the Department of Child and Adolescent Psychiatry at the Children’s Hospital of Philadelphia pointed out some concerning trends in suicide rates among young people.
For example, the rate of suicide attempts among Black youth has increased significantly over time, compared to that of white youth whose rate has remained relatively flat. In fact, a recent study found that the suicide rate of Black children under the age of 13 is now twice that of white children under the age of 13, and that this finding applies to boys as well as to girls (Bridge et al., 2018).
Historically, girls have been found to make more suicide attempts than boys, but their suicide rate is lower than that of boys. However, suicide rates among girls have risen over the years and the size of the gap between the suicide rates of boys and girls has narrowed.
Recent data shows that girls have begun using more lethal means in their attempts. African American, LGBTQ+, and youth from other minoritized groups appear to be at particularly heightened risk for both suicide and suicide attempts.
There is limited data on suicides among elementary school-aged children, as nationally representative studies have typically been conducted with adolescents (Lawrence et al., 2021). However, a recent study found that compared to early adolescents, children who die by suicide are more likely to be male or Black, to die at home, and to have experienced relationship problems with family members and/or friends.
The children were also more likely than the early adolescents to have been diagnosed with ADD/ADHD and less likely to have been diagnosed with depression/dysthymia (Sheftall et al., 2016).
Research shows that about 1 out of every 3 youth (29%) who died by suicide had disclosed their suicidal intent to someone before death (Karch et al., 2013; Sheftall et al., 2016). This highlights the usefulness of educating those who live and work with children and adolescents on how to recognize and respond to warning signs.
Moreover, there is evidence that suicidal preadolescents receive treatment at lower rates than suicidal adolescents, perhaps “due to a lack of recognition among parents and providers of the seriousness of expressions of suicidality in this age group” (Lawrence et al., 2021; Nock et al., 2013).
Youth Suicide Warning Signs
In 2013, an expert panel met at SAMHSA headquarters in Rockville, Maryland to review literature and develop a consensus list of warning signs for youth suicide. The following warning signs for youth suicide were established at that meeting and have been expanded upon in the following box.
The following signs may mean that a youth is at risk for suicide, particularly in youth who have attempted suicide in the past:
- Talking about or making plans for suicide
- Expressing hopelessness about the future
- Displaying severe/overwhelming emotional pain or distress
- Showing worrisome behavioral cues or marked changes in behavior, particularly in the presence of the above warning signs.
Specifically, this includes significant:
- Withdrawal from or change in social connections/situations, including extracurricular activities and school performance
- Changes in sleep (increased or decreased)
- Anger or hostility that seems out of character or out of context
- Recent increased agitation or irritability
- Risk taking behavior or alcohol/drug use
Risk is greater if the warning sign is:
- Has increased
- Related to an anticipated or actual painful event, loss, or change
- Associated with the acute onset of mental illness
The presence of more than one of these warning signs may increase a youth’s risk for engaging in suicidal behaviors in the near future (Adapted from Youth Suicide Warning Signs).
Some warning signs in youth are similar to warning signs in adults, such as talking about or making plans for suicide, expressing hopelessness about the future, displaying severe/overwhelming emotional pain or distress, and showing worrisome behavioral cues or marked changes in behavior.
However, with this age group, signs such as poor school performance, withdrawal from extracurricular activities, alcohol/substance use, and risk-taking behavior can add to the risk.
There is also a need to pay attention to signs of non-suicidal self-injury (NSSI), such as carving, cutting, burning, or punching oneself or objects. NSSI is more common among adolescents and young adults than among older age groups (15-20% vs. 6%).
Although by definition NSSI is intentional self-injury without the intent to die, having a history of NSSI puts one at higher risk of suicide attempt and suicide death (Klonsky et al., 2014).
The New York Times recently published a series of articles calling attention to the fact that adolescents in the U.S. have been experiencing spiraling rates of suicide, NSSI, and other mental health disorders (Richtel, 2022b).
One article in the series discussed some of the signs that an adolescent may be struggling with anxiety or depression, and how it may be difficult to determine whether these behavioral changes are indicative of a clinical problem or just normal teenage angst.
According to the article: “The question is about ‘persistence, interference with thriving, sheer suffering (on her or his part and yours) that can help make this difficult differentiation’” (Richtel, 2022a).
The article also includes some FAQs that can assist clinicians working with families/schools by providing practical advice on how families/youth counselors can help teens who may be struggling with suicidal feelings or who may be using self-harm to manage their emotions. Access these FAQs.
Lesbian, gay, and bisexual high schoolers are significantly more likely than their heterosexual peers to seriously consider suicide, attempt suicide, make a suicide plan, and make a suicide attempt requiring medical treatment, according to the 2019 Youth Risk Behavior Survey (Ivey-Stephenson et al., 2020).
These higher rates may be due to stressors, including discrimination, bullying, and family rejection, which can contribute to anxiety, depression, substance use, and other mental health challenges.
The Trevor Project, a suicide prevention and crisis intervention organization for LGBTQ youth, recently published findings from their 2021 National Survey on LGBTQ Mental Health (The Trevor Project, 2021). They surveyed 35,000 LGBTQ youth aged 13-24 years living in communities throughout the United States in 2021, during the COVID-19 pandemic.
They found that 47% of LGBTQ youth aged 13-18 had seriously considered suicide in the past year, and that 19% of these 13-18-year-olds had made a suicide attempt. These findings are fairly consistent with findings from the most recent Youth Risk Behavior Survey, which found that 47% of LGB youth had seriously considered suicide and 23% had made a suicide attempt in 2019 (Ivey-Stephenson et al., 2020; The Trevor Project, 2021).
The Trevor Project survey also found that 75% of LGBTQ youth in their overall sample had experienced discrimination based on their sexual orientation or gender identity at least once in their lifetime, with more than half reporting having experienced this in the past year.
Only 1 in 3 reported their home to be “LGBTQ-affirming.” The youth who reported having access to spaces that affirmed their sexual orientation and identity reported lower rates of suicide attempts than youth who did not have access to such spaces (The Trevor Project, 2021).
Seventy percent of the overall sample reported their mental health being poor “most of the time or always” during the pandemic. In addition, 67% of the 13-17-year-olds in the sample reported having had symptoms of major depressive disorder in the past two weeks, which is significantly higher than the 40% rate found in the 18-24 age group. Rates of anxiety were high in both groups (73% in the 13-17-year-old, 69% in 18-24-year-olds).
Finally, the 2021 National Survey on LGBTQ Mental Health found that nearly half (48%) of those who had wanted counseling from mental health professionals during the previous 12 months did not receive it (The Trevor Project, 2021).
Additional research is needed on how to reach and support this very vulnerable group.
In addition to its research arm, the Trevor Project offers free and confidential suicide prevention and crisis intervention services to support LGBTQ youth. These services are available 24/7 via phone (TrevorLifeline), text (TrevorText), and chat (TrevorChat).
They also run TrevorSpace, a safe space social networking site for LGBTQ youth, as well as educational and public awareness programs. These resources can be accessed at thetrevorproject.org.
School Bullying and Cyberbullying
School bullying has long been associated with mental health consequences in children and adolescents, including suicide ideation, attempts, and deaths (Hinduja & Parchin, 2010), though no study has demonstrated a causative relationship. The mental health risks associated with cyberbullying have more recently come to attention (Dorol-Beauroy-Eustace & Mishara, 2021; Hinduja & Patchin, 2018; Zaborskis et al., 2019).
Studies show that both school bullying and cyberbullying may independently increase suicide risk, but the risk appears to be greater among students who report being victims of both school bullying and cyberbullying (Baiden & Tadeo, 2020; Zaborskis et al., 2019).
Cyberbullying has been defined as “willful and repeated harm inflicted through the use of computers, cell phones, and other electronic devices” (Hinduja & Patchin, 2018, p. 208).
A 2018 Pew survey found that a majority of teens have experienced some form of cyberbullying (Anderson, 2018; Cook, 2022), though not all studies have found this high of a rate (Cook, 2022; Patchin, 2019). However, incidents of cyberbullying have clearly increased during the pandemic, at least in part due to the increased time youth have been spending online (e.g., online school; leisure activity) (Cook, 2022).
Studies have uncovered a number of risk factors for suicidal behavior among those who have been cyberbullied. Most of these are factors already identified as associated with suicidal behavior in general (e.g., psychiatric and substance use disorder, stress, loneliness, psychological distress) and not specific to those who have been cyberbullied (Dorol-Beauroy-Eustace & Mishara, 2021).
Findings may also be limited by the self-report nature of the data. For example, youth who report more frequent or more severe cyber harassment are also more likely to report suicidal ideation and attempts (Hinduja & Patchin, 2018; Dorol-Beauroy-Eustace & Mishara, 2021).
Nevertheless, youth who have been cyberbullied because of their racial/ethnic background, gender identity, or sexual orientation appear to be particularly at risk. This group was 6.85 times more likely to report suicidal ideation and 7.85 times more likely to attempt suicide compared to a control group of youth who were either not cyberbullied or were cyberbullied for other reasons (Sinclair et al., 2012; Dorol-Beauroy-Eustace & Mishara, 2021).
Protective factors have been studied less than risk factors. However, limited research suggests that factors that mitigate suicide risk in other populations will mitigate risk in this situation, too. For example, school connectedness has been shown to moderate the relationship between cyberbullying and suicidal behavior in an adolescent sample (Dorol-Beauroy-Eustace & Mishara, 2021; Kim et al., 2019).
A few studies have explored suicide risk in cyberbullying perpetrators. A recent systematic review found that perpetrators were 1.23 times more likely to experience suicidal ideation and 1.21 times more likely to exhibit suicidal behavior than the nonperpetrators.
In this same review, compared to nonvictims, cyberbullying victims were 2.15 times more likely to report having suicidal thoughts, 2.10 times more likely to report suicidal behavior, and 2.57 times more likely to report having made a suicide attempt.
If we extrapolate from these findings, it appears that while there is a modest increase in the risk of suicidal ideation and behavior among perpetrators, the victims are at more than double the risk (John et al., 2018).
The vast majority of research in this area has looked at the correlation between having been a victim of bullying and reporting suicidal ideation and/or a suicide attempt. Most studies were cross-sectional as opposed to longitudinal in design, and did not look at suicide death as an endpoint (Klomek et al., 2010).
One longitudinal study by Klomek and colleagues (2009) examined the relationship between childhood bullying behaviors at age 8 and suicide attempts and deaths at age 25. They found that while there was a relationship between bullying and suicide attempts and death in their sample, the relationship varied by sex.
Specifically, the relationship between frequent bullying and later suicide attempts and deaths disappeared for males in the study after controlling for baseline psychopathology, but remained for the females. However, this study had several limitations, including the small number of suicides, especially among the females. There were only 2 suicides out of a cohort of about 1,000 females who had been bullied and followed for nearly 15 years.
Thus, as stated on stopbullying.gov, a website managed by the U.S. Department of Health and Human Services: “We don’t know if bullying directly causes suicide-related behavior. We know that most youth who are involved in bullying do NOT engage in suicide related behavior. It is correct to say that involvement in bullying, along with other risk factors, increases the chance that a young person will engage in suicide-related behaviors” (Vivolo-Kantor et al., 2013).
Clinicians treating children and adolescents, and especially those working with marginalized youth, might consider routinely asking about bullying and cyberbullying as further screening for suicide risk may be indicated.
There is also a significant risk of suicidal thoughts and behavior among perpetrators, suggesting that typical school discipline relying on isolation might not be the best approach in this instance. Studies (e.g., Bauman et al., 2013) have also uncovered a link between having been a victim and being a perpetrator of bullying (John et al., 2018).
However, future efforts to reduce bullying and its mental health consequences must be attuned to the unique needs of both of these vulnerable groups (John et al., 2018).
McLean Hospital has information on its website concerning “The Mental Health Impact of Bullying on Kids and Teens.” This includes how to recognize bullying, what to do if you witness bullying taking place, and where to find help. Access this webpage.
Assessment of Patients Aged 10-24 Years
Record numbers of children and adolescents have been presenting to emergency departments for mental health issues, especially for deliberate self-harm and substance use.
A recent study found that while the total number of ED visits for children aged 5 to 17 years remained stable between 2007 and 2016, there was a 60% increase in pediatric ED visits for mental health disorders, a 159% increase in visits for substance use disorders, and a 329% increase in visits related to deliberate self-harm (Lo et al., 2020).
The National Institute of Mental Health (NIMH) has developed a Brief Suicide Safety Assessment Guide to be used with patients aged 10-24 years old.
Children and adolescents under the age of 18 can be interviewed together with a parent or guardian, if one is available. For patients who are 18 years of age or older, the patient’s permission is necessary in order for the parent or guardian to join the interview (this varies by state: in some states the minimum age for self-consent is 16).
The parent or guardian can also be involved in creating a safety plan for managing suicidal thoughts that may arise in the future.
Suicide risk assessments of adolescents and young adults, especially those with a mood disorder, typically include questions about the presence of non-suicidal self-injury (NSSI), as NSSI has been associated with suicide attempts in this population and others.
The assessment for NSSI may include questions about the presence of intent to die, the function of or reasons for engaging in the behavior, methods used, frequency and severity of past self-injurious behavior, and the presence of plan and intent to engage in future self-injury (Nock et al., 2006).
The exact rate of suicide among college students is not entirely clear. However, the rate of suicide appears to be lower among college students than their non-student peers (Arria et al., 2009). Male students older than 25 showed particularly high rates of suicide, and graduate students have higher rates of suicide than undergraduate students (Haas et al., 2003).
The lower suicide rate found on campus compared to a national sample has been attributed to several factors, including (Haas et al., 2003; Silverman et al., 1997):
- More readily available no-cost or low-cost health insurance on campus
- More supportive peer and mentor environment on campus
- Campus prohibitions on the availability of firearms
- Greater restriction and monitoring of alcohol use on campus
- Clearer sense of purpose among college students
However, the incidence of suicide among college students is difficult to interpret from individual studies due to variations between studies in the definition of a “college suicide.” Some studies identified only those suicides that took place on campus, whereas others would include all suicides that occurred while the student was enrolled, regardless of the actual location of the suicide.
Some studies have been criticized for not distinguishing full-time from part-time students and for not including former students who fail to graduate. In longitudinal studies, dropping out of college has been associated with a greatly increased risk of suicide (Haas et al., 2003).
The 2008 American College Health Association assessment of 26,685 students in 40 postsecondary institutions found that 1.3% of college students had attempted suicide and 6.4% had seriously considered suicide at least once in the past 12 months (Wilcox et al., 2010).
Risk Factors for Suicide in College Students
Suicide in college students, like suicide in other population samples, is always multifactorial (APA, 2003).
- Low social support
- Substance abuse
- Adverse life events
- Family history of suicide
- Sexual abuse
- Troubled relationships
- Difficulties with sexual identity
(Mackenzie et al., 2011; Arria et al., 2009)
Most mental disorders have their first onset by age 24. College students are in the high-risk age group (18 to 25 years) for the manifestation of symptoms of the more common mental health disorders, including depression, bipolar disorder, schizophrenia, anxiety, and substance abuse problems (Cook, 2007).
The 15-21 age category (which are typically the college years) has the highest past-year prevalence rate of mental illness (Mackenzie et al., 2011).
Nyer et al. (2013) examined potential factors that may distinguish college students with depressive symptoms and suicidal ideation from those college students with depressive symptoms but no suicidal ideation.
The sample was composed of 287 undergraduates with total scores greater than 13 on the Beck Depression Inventory. They found that the suicidal students were more symptomatic than the non-suicidal students (i.e., they had significantly higher levels of depressive symptoms, hopelessness, and anxiety).
However, contrary to expectations, the non-suicidal and suicidal students did not differ on measures of cognitive and physical functioning or grade point average.
Monitoring and treating comorbid symptoms of anxiety when students present with depressive symptoms, as well as asking about suicidal ideation even when a student may not appear functionally impaired, can be useful. Nyer et al. (2013) state: “Lack of functional impairment in students with SI may be one of the reasons why suicide of young people appears to occur unexpectedly.” (p. 7).
Alcohol and substance use has been linked to suicide ideation and suicide attempts in college students (Arria et al., 2009). Eighty percent of college students drink alcohol, and half of college student drinkers engage in heavy episodic drinking (Lamis et al., 2009).
College students who binge drink in solitary contexts (i.e., while alone) experience greater depression and suicidal ideation than students who only binge drink in social contexts (Gonzalez, 2012). Studies have found evidence of alcohol/substance abuse in 38 to 54 percent of adolescent and young adult suicide victims (Miller & Glinski, 2000). In addition, prescription opioid use has been correlated with suicidal ideation and attempts in college student samples (Zullig & Divin, 2012).
Student groups that have elevated rates of suicide include students with learning disabilities, who have been found to be twice as likely as other college students to attempt suicide (Svetaz et al., 2000; Shadick & Akhter, 2014), and LGBTQ+ students, who have significantly higher rates of suicidal ideation and attempts than heterosexual peers (Shadick & Akhter, 2014).
Intimate partner or physical dating violence also increase risk for suicide in college students (Daniels, 2005). Mackenzie et al. (2011) found that unwanted sexual encounters and a history of physical violence were associated with depression in their college health clinic sample.
Blosnich and Bossarte (2012) found that gay and lesbian college students who experienced any intimate partner violence in the past 12 months had greater than twice the odds of suicidal ideation in the past 12 months compared with gay and lesbian students who did not experience intimate partner violence.
Clinicians may decide, when indicated, to screen for intimate partner violence to assure that students are not placed back into a dangerous situation, that an abusive partner is not mistakenly cited as a source of social support, and that referral to additional services can be offered (Blosnich & Bossarte, 2012). It is not unusual for persons to feel uncomfortable disclosing intimate partner violence even though this presents a problem in their lives that needs to be addressed (Daniels, 2005).
Another area of inquiry in the young adult population are text and social media communications and other forms of cyberbullying. Some recent criminal cases in Massachusetts have uncovered abusive text messages and phone calls contributing to suicide (e.g., Andersen, 2019).
In addition, clinicians who see college students may need to assess for parent-child conflict and, if relevant, address this issue in therapy (Lamis and Jahn, 2013).
Summary of Suicide Risk Factors in College Students
The Suicide Prevention Resource Center (SPRC) has a fact sheet titled “Suicide Among College and University Students in the United States,” which summarizes the risk factors in this population (SPRC, 2014):
- Behavioral health issues/disorders: Depression; substance use; conduct disorders; other disorders (anxiety, eating disorders); previous suicide attempts; NSSI.
- Individual characteristics: Hopelessness, loneliness, social isolation, lack of belonging, anger/hostility; risky behavior, impulsivity; low stress and frustration tolerance; poor problem-solving or coping skills; perception of being a burden.
- Adverse/stressful life circumstances: Interpersonal difficulties or losses (e.g., relationship breakup, dating violence); school or work problems; financial problems; physical, sexual, and/or psychological abuse (current and/or previous); chronic physical illness or disability.
- Family characteristics: Family history of suicide or suicidal behavior; parental mental health problems; family violence or abuse (current and/or previous); family instability and/or loss; lack of parental support.
- School and community factors: Limited access to effective health or mental health treatment; stigma associated with seeking care; negative social and emotional environment (negative attitudes, beliefs, feelings, interactions of staff and students); discrimination based on sexual orientation, gender identity, race and ethnicity, or physical characteristics (e.g., being overweight); access to lethal means; exposure to media normalizing or glamorizing suicide.
Treatment Utilization in the College Population
The majority of students who die by suicide do so without ever entering a therapist’s office (Eisenberg et al., 2012). One study, for example, found only 23% of college students who committed suicide had been seen by their college counseling center (Cukrowicz et al., 2011; Schwartz, 2006).
Treatment utilization in the college population is higher among women, white students, and those who have friends or family members who have been in treatment (Eisenberg et al., 2012; Masuda et al., 2009).
Indeed, the Healthy Minds Study found that 40% of white students with mental health problems received treatment compared to 28% of Hispanic students, 26% of Black students, and 15% of Asian students (Eisenberg et al., 2012). International students are also less likely than domestic students to seek counseling (Shadick & Akhter, 2014). Those with close friends or family members in treatment were more likely to seek help for themselves (Eisenberg et al., 2011; 2012).
One reason cited for not seeking help was the cultural competence of mental health services. In the Healthy Minds Study, 9% of non-white students cited “People providing services aren’t sensitive enough to cultural issues” as an important reason for not receiving services.
Twenty-three percent of students with sexual orientations other than heterosexual cited “People providing services aren’t sensitive enough to sexual identity issues.” Other common barriers to seeking help were “I don’t have time,” “I prefer to deal with these issues on my own,” “Stress is normal in college/graduate school,” and “I question how serious my needs are” (Eisenberg et al., 2012).
Please reference the “Race, Ethnicity, and Culture” section of this guide for resources on providing culturally-competent care.
Older adults are the fastest growing segment of the population in the U.S. and in most countries worldwide. Over the next 30 years, estimates are that the population over age 65 will double and the number over 85 will triple. These demographic changes are fueled by aging into late life of the large post-WWII “baby boom” generation.
The expansion of the older adult cohort poses great challenges for suicide prevention. Among the large majority of countries that report suicide statistics to the World Health Organization, the rate of suicide tends to rise with age for both men and women to peaks in old age (World Health Organization, 2000).
Although in the U.S. the suicide rate among women rises to midlife then decline modestly thereafter, rates for men continue to rise to a peak in those over age 80 of 44/100,000, or almost four times the rate of the general population (CDC). The pattern varies among ethnic and racial subgroups, with older white men representing the highest risk group.
The risk of suicide in a particular age cohort tends to remain stable relative to other age cohorts. Demographic analyses indicate that baby boomers have carried higher suicide rates with them through life than preceding or subsequent age cohorts.
The recent rise in both the absolute numbers and rates of suicide in older people therefore likely reflects the entry of the baby boom cohort into older age (the leading edge of baby boomers reached age 65 in 2011), a period of elevated risk among an especially high-risk cohort. That pattern is likely to continue for many years, underscoring the public health imperative of suicide prevention for older adults.
Characteristics of Suicide in Later Life
In addition to the growth of the older population fueled by aging of the baby boom cohort, several unique characteristics of suicide in later life pose challenges to its prevention.
First, suicidal behavior appears to be more lethal in older people. Whereas approximately 50% of suicides in the U.S. are by firearm, almost three quarters of older adults who take their own lives do so by this immediately lethal method (National Vital Statistics Reporting System, 2019).
As well, the preparations that suicidal older adults make to end their lives tend to be more planful and deliberate than the suicides of younger people (Conwell et al., 1998). That is, they act with greater lethality of intent.
Furthermore, any injury sustained by an older person is more likely to result in death because of their greater likelihood of physical illness and more limited physical reserves. Older adults are more likely than younger groups to be socially isolated, less likely to discuss their emotional distress with others, and less likely to endorse depression or suicidal ideation, making recognition of high-risk states more difficult as well (Van Orden et al., 2019).
Using a range of rigorous research methods including retrospective “psychological autopsy” studies, prospective cohort studies, and linkage of disease registries with mortality records, investigators have identified factors that place older people at increased risk for suicide. As a memory aid, we refer to them at the “5 Ds” (Van Orden et al., 2019).
Any psychiatric illness is associated with increased risk for suicide on the order of 40-80 times. Affective disorder (major and minor depression in particular, but also bipolar disorder and even subsyndromal depressive states) are more common in late life suicides than other disorders.
Dementia or mild cognitive impairment is also associated with significantly increased risk although even less likely than clinical depression to be diagnosed. A history of prior suicide attempts greatly increases risk for subsequent suicide as well.
Physical illness increases risk of suicide in later life by a factor of about 2. The illnesses most closely associated with suicide are neurological disorders and cancers.
Functioning sufficient to perform the usual activities of daily living and maintain independence is central to quality of life in old age. Loss of functional abilities has also been associated with suicide in this age group, independent of other factors.
Both theory and research link subjective (e.g., loneliness) and objective measures of social disconnection (e.g., living alone, few social supports) to suicide in older people.
As noted previously, over 70% of suicides in later life are by a firearm. Presence of a handgun in the home has been associated with increased risk of suicide death in an older person, regardless of how it is stored.
Another characteristic of older people who take their own lives is that they are less likely than younger persons to have visited a mental health care professional. Instead, they visit primary and specialty care providers; up to a third of older adults who killed themselves saw their PCP in the last week of life, suggesting opportunities to intervene in that setting (Amhedani et al., 2014; Luoma et al., 2002).
Given the central role that clinical depression plays in late life suicide (Conwell et al., 1996), routine screening with tools such as the PHQ-9 (Kroenke et al., 2001) or Geriatric Depression Scale (Montorio & Izal, 1996) is recommended in primary care practice.
Although routine screening for suicidal ideation in primary care is not recommended by the U.S. Preventive Services Task Force (USPSTF, 2013), clinicians should be prepared to ask the patient about whom they have concern if he or she has had thoughts that life is not worth living, thoughts of suicide, considered a means by which they would end their lives, and whether they have rehearsed the act.
Also, because of the close association of suicide in later life with firearms, routine screening for access to deadly means is an important preventive measure, and where there is concern about an older adult’s safety, consideration should be given to removing firearms from the home on a temporary basis.
Having systematically reviewed the older person’s mental, physical, functional, and social context, screened for depression using standardized measures and for access to firearms, and assessed the extent and nature of suicidal thoughts they may have, a plan to assure the person’s safety and treat the conditions driving suicide risk should be developed.
For those with histories of suicidal ideation or behavior, the Safety Planning Intervention (SPI) has been shown effective in reducing recurrent episodes of self-harm (Stanley et al., 2018). The SPI is a structured interaction by which the clinician and patient collaboratively develop individually tailored contingency plans for managing periods of increased stress, helping to assure their safety. It should then be coupled with plans for further assessment and treatment.
Indicated preventive interventions are those targeting individuals at high risk for suicide. Evidence-based psychotherapies (cognitive behavior therapy [CBT], problem-solving therapy [PST], and interpersonal psychotherapy [IPT]) and, for those with depressive illness, treatment with antidepressant medications appear effective in reducing suicidal ideation and behavior in older adults. Close follow-up to assure ongoing improvement is indicated (Van Orden et al., 2019).
Because suicidal states tend to be more lethal in later life, it is perhaps even more important to intervene early among those with risk factors but who have not yet become suicidal—so called “selective” preventive interventions (Conwell, 2014).
Such treatments are not typically thought of as suicide prevention, but nevertheless save lives. They include active treatment of the physical illnesses associated with suicide in later life; aggressive pain management; therapy services designed to optimize the older person’s independent functioning; and supports for the older individual’s social connectedness and ability to age in place.
The settings for these interventions are more often in the community (e.g., through aging services agencies and Area Agencies on Aging) and primary and specialty medical care, than traditional mental health practice. The advent of care models in which mental health, physical health, and non-medical social services for older adults are integrated and delivered in a coordinated manner is a promising development for reducing suicides in this age group.
Finally, negative societal attitudes and misperceptions about aging contribute to risk for suicide in older people as well. The commonly held belief that later life is an unhappy time rife with loss and illness belies the fact that older adults are on average more satisfied with their lives than younger and middle-aged adults (Carstensen et al., 2011). It is not normal for an older person to be depressed or to think that their life is not worth living, but rather an indication for assessment, diagnosis, and care.
One of the DSM-5 changes that came out in 2013 is the use of the term “perinatal depression” as opposed to “postpartum depression.” The diagnosis of perinatal depression requires that the depression occurs during the pregnancy or during the first four weeks postpartum.
The diagnostic criteria did not change in DSM-5, but the time period for relevant symptoms was extended (Stuart-Parrigon & Stuart, 2014). Perinatal depression also includes episodes that begin prior to pregnancy and persist during the pregnancy.
Risk Factors for Suicidal Ideation in Pregnant Women
- Living in urban areas
- Pregnant teens with limited social support
- Being 20 or younger
- Having fewer than 12 years of education
- Intimate partner violence
- History of major depressive disorder
(Coelho et al., 2014; Gandhi et al., 2006; Gelaye et al., 2016)
While pregnant women are more likely than the general population to experience suicidal ideation, they are less likely than their non-pregnant counterparts to die by suicide (Gelaye et al., 2016). This finding holds both in the U.S. and abroad (Appleby, 1991; Gissler et al., 2005; Gelaye et al., 2016; Marzuk et al., 1997; Samandari et al., 2011).
Nevertheless, suicidal ideation and attempts during pregnancy have been associated with adverse consequences, including low birth weight (Gelaye et al., 2016; Gandhi et al., 2016). In one study, infants born to mothers who reported depressive symptoms with suicidal ideation weighed 240 grams less on average than infant born to mothers who reported depressive symptoms without suicidal ideation (Gelaye et al., 2016; Hodgkinson et al., 2010).
Risk Factors for Suicide Completion in the Perinatal Period
- Younger Maternal Age
- Unpartnered Relationship Status
- Unplanned Pregnancy
- Non-Caucasian Race
- Shorter Psychiatric Illness Duration
- Preexisting Psychiatric Illness
- Current Psychiatric Diagnosis
(Orsolini et al., 2016)
The suicide rate among women who have given birth in the last year is also significantly lower than the suicide rate among women who have not given birth. Nevertheless, suicide still occurs in postpartum women and, in fact, is one of the most common causes of maternal death in the year following delivery, accounting for about 20% of postpartum deaths (Lindahl, Pearson, & Colpe, 2005; Wisner et al., 2013).
In addition, diagnoses of suicidality in childbearing women has increased steadily between 2006 and 2017 (Admon et al., 2020). Women with a postpartum psychiatric hospitalization can be at greater risk for suicide during the first postpartum year than women without a postpartum psychiatric hospitalization (Appleby et al., 1998; Oates, 2003; Orsolini et al., 2016).
The risk of both first onset and recurrence of bipolar disorder is increased during the postpartum period. Nearly a quarter (22.6%) of postpartum women who screened positive for depression in one study had bipolar disorder (Wisner et al., 2013).
A bipolar depression requires a different form of treatment than unipolar depression, including use of a mood-stabilizer, such as lithium. Second-generation antipsychotics (cariprazine, lurasidone, olanzapine+fluoxetine, quetiapine) and cautious use of an antidepressant may be indicated, depending upon clinical response.
While many mothers may prefer not to use medication in the perinatal period, there is now sufficient research support to suggest that, especially in the case of severe depression, it is more beneficial for both the mother and the child for the depression to be treated.
Many women need to take medication to achieve and maintain a euthymic mood during pregnancy and breastfeeding. Medication should not be discontinued without extensive discussion with prescribing physicians and/or other consultants.
Postpartum psychosis is relatively rare. It occurs in about 1 or 2 in 1000 deliveries (Luykx et al., 2019), compared to postpartum depression which occurs in 1 in 9 women (Ko et al., 2017).
Symptoms of Postpartum Psychosis
- Suicidal or infanticidal thoughts
- Delusions or strange beliefs
- Feeling very irritated
- Decreased sleep
- Paranoia or suspiciousness
- Rapid mood swings
- Difficulty communicating at times
(Postpartum Support International)
Women with this diagnosis often do not express their suicidal or infanticidal thoughts (Lukyx et al, 2019). One study has indicated that approximately 5% of women with postpartum psychosis ultimately die by suicide (Lucchesi, 2018). While suicide is uncommon during the immediate postpartum psychosis, it becomes more common during subsequent psychotic episodes and later in life (Brockington, 2017).
Approximately one in three women who have experienced postpartum psychosis experience recurrence with subsequent pregnancies (Bergink et al., 2016). The most significant risk factors for postpartum psychosis are a previous psychotic episode and a personal or family history of bipolar disorder. There is an increased incidence of suicide among first-degree relatives of women with postpartum psychosis.
The rate of infanticide in women with a history of postpartum psychosis is approximately 4% (Lucchesi, 2018). Antipsychotics, lithium, and ECT can be effective for postpartum psychosis. Inpatient care is usually required (Bergink et al., 2016).
Murder-suicide, also known as homicide-suicide, is when an individual kills one or more people before taking their own life. It is necessary for the two acts to occur in close proximity—in most cases, the suicide occurring within seconds or minutes of the homicide. Murder-suicides are very rare, with fewer than 1/year per 100,000 people occurring in the United States (Knoll, 2016). They account for only about one to two percent of all suicides (Jacobs, 1999; Joiner, 2014).
Murder-suicides have been classified according to type and class. Type refers to the relationship between the perpetrator and victim. There are three types of murder-suicide: spousal/consortial, familial, and extrafamilial.
Class refers to the principal motive or the precipitant for the murder-suicide. Some examples of classes are amorous jealousy, mercy killing, retaliation, and family financial or social stressors. Certain types of murder-suicides have been associated with certain classes.
For example, spousal/consortial suicides are more likely to involve amorous jealousy, whereas familial suicides are more likely to be mercy killings because of the declining health of either the victim or the offender (Jacobs, 1999; Marzuk et al., 1992).
The majority of murder-suicides in the U.S. are perpetrated by men. Most cases involve a man killing a romantic partner or ex-romantic partner before killing himself. Common contributing factors are estrangement and history of domestic violence leading to impending divorce or separation.
In the elderly, however, most murder-suicide cases involve an older male caregiver killing his ailing wife and then killing himself. Firearms are the most common method of homicide-suicide. Depression is common among perpetrators (Eliason, 2009).
The perpetrators of murder-suicide typically have a low rate of prior criminal behavior. This, along with the rarity of murder-suicide, makes prediction impossible. As with attempts to predict simple suicide and homicide, any evaluation of murder-suicide is likely to overpredict mortality. Most individuals who fit the profile will never die in a murder-suicide event (Eliason, 2009; Jacobs, 1999).
Patients who present with a recent suicide attempt, have a suicide plan, or voice suicidal ideation may need to have their risk of violent or homicidal behavior assessed. Likewise, patients who present with recent violent behavior or homicidal ideations may need to be evaluated for suicidal behavior.
Although there are few studies that address the concurrence of homicidal and suicidal ideation, one psychological autopsy study estimated that 10-15% of patients who experience suicidal ideation also experience homicidal ideation (Brent et al., 1993).
Components of murder-suicide risk assessment include:
- History of domestic violence
- Access to lethal means, particularly a firearm
- Postpartum psychosis
- Suicide attempt, suicide plan, or suicidal ideation in context of interpersonal crisis
- History of financial stress in combination with severe relationship turmoil
- Obsessive or delusional jealousy, especially when comorbid with depression or paranoia
- Older males caring for a deteriorating partner
Interventions will include treating psychiatric symptoms, determining the need for hospitalization, removing access to firearms and other lethal methods, and connecting patients to psychosocial supports and other social services (APA, 2003).
Individuals With Substance Use Disorders
Substance use disorders have been associated with increased risk of suicide death, even after controlling for known risk factors, such as psychiatric and physical health conditions (Lynch et al., 2020).
While all substance use disorders carry an elevated risk of suicide, the risk is greatest for alcohol and opioid use disorders (Rizk et al., 2021). Persons with alcohol use disorder and opioid use disorder are 10-15 times more likely to die by suicide than the general population (Connery, 2021). Suicide risk is elevated even during times of abstinence or remission (Connery, 2021; Rizk et al., 2021).
As with the general population, more men with substance use disorders will die from suicide than women. However, the strength of the association between substance use disorders and suicide is greater for women than it is for men (Lynch et al., 2020).
Researchers suggest that women may be more reluctant than men to seek treatment for their substance use, so that the women who are diagnosed have a more severe substance use disorder (Lynch et al., 2020).
Opioid use disorder carries the greatest risk of suicide, as well as mortality. Persons who use opioids are 14 times more likely to die by suicide than the general population (Harris and Barraclough, 1997; Rizk et al., 2021; Wilcox et al., 2004). The relative risk of suicide and fatality with opioids is five times that of other substances (Connery, 2021). Opioid users have elevated mortality risk for both drug poisoning and suicide and this increased risk of death persists through age 65 (Connery, 2021).
There are a number of reasons why substance use may increase suicide risk. Individuals with substance use disorders are likely to have co-occurring depressive disorders and we know that having a depressive mood disorder, particularly bipolar disorder, is a leading risk factor for both and substance intoxication (Baldessarini, 2021; Connery, 2021).
Substance use disorder and substance intoxication are also both correlated with novelty-seeking and other impulsive behaviors, as well as the use of more lethal suicidal behavior (Connery, 2021; Rizk et al., 2021). There also may be shared neurobiological and social factors for substance use disorders and suicide risk (e.g., social isolation, unemployment, housing insecurity, childhood trauma, legal stressors) (Connery, 2021; Rizk et al., 2021).
Moreover, frequent exposure to premature mortality may desensitize to death and increase the individual’s capacity for self-harm behavior, especially among those who are struggling with opioid use disorder (Connery, 2021). Fear of death and ambivalence surrounding death protect many individuals from taking their lives.
Suicide and mortality risk in opioid users is further increased with alcohol misuse (Connery, 2021; Rizk et al., 2021). In general, polysubstance use—having more than one substance use disorder (e.g., alcohol + drug + tobacco)—is known to increase suicide risk (Lynch et al., 2020).
Using opioids together with alcohol also increases one’s risk of unintentional overdose via respiratory depression (Rizk et al., 2021). The risk of an overdose being fatal is greatest if an opioid or barbiturate was used (Miller et al., 2020).
Alcohol and opioids are the most common substances found in suicide decedents. Twenty-two percent of suicide deaths involve alcohol, 20% involve opioids (Connery, 2021; Rizk et al., 2021). However, there is reason to believe that suicide deaths involving these substances are significantly undercounted (e.g., Abiragi et al., 2020; Rockett et al., 2018).
While recent data reports a reduction of suicides by 5.6% between 2018 and 2020, some question whether this reduction is actually due to misclassification as accidental drug overdose deaths. The number of drug overdoses increased by nearly 40% during this very same time period, from 67,367 drug overdose deaths in 2018 to 93,331 deaths in 2020 (Ahmad, 2021; CDC, 2021; Wilson et al., 2020).
A recent study, which isolated data based on age, gender, and race, found that between 2015 and 2019 suicides by intentional drug overdose significantly increased among youth aged 15-24, elderly adults aged 75-84, and Black women (Han et al., 2022).
To call a death a suicide, one looks for evidence of “[b]ehavior that is self-directed and deliberately results in injury or the potential of injury to oneself” and implicit or explicit evidence of suicidal intent. Explicit evidence of suicide intent includes suicide notes, internet search for methods, final communication to others. Evidence of implicit intent includes being found shot by your gun in your own home or being found dead of carbon monoxide poisoning in your own garage (Connery, 2021).
However, as Dr. Connery (2021) stated in a recent presentation, substance use is neither explicit nor implicit evidence of suicidal intent and some jurisdictions will call any deaths with “prominent intoxication” an accidental death.
Intentionality of an opioid user falls on a spectrum, from “I don’t think I will die even though I’m misusing opioids” to “My life is pointless; today is a good day to die.” (Connery, 2021). Connery and colleagues (2019) found that over a third (36%) of opioid overdose survivors reported that they had a strong desire to die before their overdose, whereas 41.51% reported no desire to die at the time.
While there is significant overlap, those who intentionally overdose on opioids and those who unintentionally overdose are likely distinct groups with distinct clinical correlates.
For example, more females intentionally overdose, whereas more males accidentally overdose. In addition to gender, risk factors for suicide among opioid users include higher dose, older age, comorbid disorder, and a low sense of belonging (e.g., Webster, 2017).
Researchers, using the psychological autopsy method, also found several factors distinguishing opioid deaths categorized as accidents from opioid deaths categorized as suicides.
Though the sample size was small, accidental opioid deaths were more frequently found in men, those with more severe substance use disorders, those who had a prior nonfatal overdose, and those experiencing family conflict.
Suicide deaths was more common in those with evidence of a depressive disorder, prior suicide attempt, and greater number of total lifetime stressors. Opioid users who died by suicide were significantly more likely to have experienced the end of a romantic relationship in the 6 months prior to death. They also showed more evidence of recent planning for death (Athey et al., 2020; Connery, 2021).
Having a prior nonfatal overdose has also been associated with both future fatal overdose and future suicide in large population studies (Connery, 2021; Olfson et al., 2018). Unfortunately, there are also racial disparities in treatment following hospitalization for deliberate drug overdoses, with non-Hispanic Blacks significantly less likely than non-Hispanic Whites to receive a mental health assessment during hospitalization and to be discharged to an inpatient psychiatric facility (Charron et al., 2019; Connery, 2021).
Drug poisoning deaths have also increased disproportionately among Black populations. Persons who lack insurance are also less likely to be discharged to an inpatient psychiatric facility after hospitalization for a deliberate drug overdose (Charron et al., 2019).
Studies show that a significant portion of those entering treatment for opioid use disorder report at least one prior suicide attempt (Connery, 2021). Prior suicide attempt has been shown to be one of the most consistent correlates of future suicidal behavior (Baldessarini, 2021; Ribeiro et al., 2016). It is thus important in this population to take a careful history of depressive symptoms and other factors associated with acute suicide risk (Connery, 2021).
During a recent presentation, Dr. Connery (2021) discussed some conversation starters that may help clinicians who work with individuals with opioid use disorders. These include:
- “Has it gotten so bad that you wished you were dead?”
- “I know that you’re telling me about your relapse, but I’m actually more concerned that you’re spending time thinking about your own death.”
- “You told me that you planned to use last week, and that you were not going to carry your naloxone with you, which is different from before. What do you think about this?”
- “You’re taking more risks than you usually do. What’s going on?”
Emergency department patients who come in with an overdose are frequently screened for suicide risk, so that, if positive, they can be referred for appropriate treatment. The Columbia Protocol provides a screener with triage specifically for use in Emergency Departments. Access this screening instrument.
Educating substance-using patients and their families on how to recognize and respond to suicide planning and preparation is also important as is the need to create a personalized safety plan, when indicated (Connery, 2021; Olfson et al., 2018).
Because the number of firearm suicides among persons with opioid use disorder is even greater than the number of overdose suicides, clinicians, when indicated, can discuss restricting access to all lethal means, not just pills, with these patients and their loved ones (Oquendo & Volkow, 2018).
As discussed earlier in this resource, medication for addiction treatment, specifically buprenorphine and methadone, has been shown to significantly reduce suicide mortality in opioid users (Ahmadi et al., 2018; Fazel & Runeson, 2020; Molero et al., 2018; Mooney, 2022; Watts et al., 2022; Yovell et al., 2015).
It can also be useful for clinicians to focus efforts on abstinence and recovery care, sleep hygiene, pain relief, peer and community support, and establishing reasons for living. Harm reduction in substance use disorder also includes reducing the number of substances used, avoiding activities such as driving or swimming, and carrying naloxone rescue (Connery, 2021).
Finally, reducing opioid suicides may require a public health response that is different from the current response, which is currently aimed at preventing unintentional fentanyl overdoses.
The first study finding an association between cigarette smoking and suicide was published in 1969 (Li et al., 2012; Paffenbarger et al., 1969). Since that time, many studies have been published on this topic, including a few meta-analyses.
For example, Poorolajal & Darvishi (2016) found in their meta-analysis of 63 studies that current smokers have a higher risk of suicide ideation, plans, attempts, and deaths than nonsmokers. In a meta-analysis of 15 prospective cohort studies, Li and colleagues (2012) found that current and former smokers are both at increased risk of death by suicide than never smokers. Furthermore, among smokers, the risk is significantly higher for current smokers than former smokers.
There also appears to be a dose-response relationship between cigarette smoking and suicide. In their meta-analysis, Li and colleagues (2012) estimated that for every additional 10 cigarettes smoked per day, the risk of suicide increased by 24%.
A cohort study of over 300,000 male active-duty Army soldiers also found increased suicide risk among those who smoked more cigarettes per day. Active-duty soldiers who smoked more than 20 cigarettes a day were twice as likely to die by suicide than those soldiers who never smoked (Miller et al., 2000).
While there is a clear association between cigarette smoking and suicide, the reason for the association is less certain. Some have posited that smoking and suicide are not causally related, but rather that some individuals may be predisposed to both smoking and suicide (e.g., Miller et al., 2000). Biological, social, and causal explanations have been proposed, many of which are plausible (Green et al., 2017).
For example, with respect to biology, smoking may lead to depression by altering brain chemistry. We know that smoking decreases serotonin (Green et al., 2017; Malone et al., 2003). We also know that nicotine is a strong activator of the hypothalamic-pituitary adrenal axis (Green et al., 2017; Rohleder & Kirschbaum, 2006). These two biological mechanisms may play role in the link.
Smoking is also associated with tobacco-related diseases (e.g., cancer, COPD), which can be painful and debilitating (Green et al., 2017; Li et al., 2012). Physical health conditions, especially those involving chronic pain or functional impairment, are known risk factors for suicide (e.g., Racine, 2018; Tang & Crane, 2006).
Pre-existing or co-occurring mental illness may partially account for the finding (Green et al., 2017). It has been posited that smoking can be a form of self-medication for depression (Li et al., 2012).
There is also significant overlap between mental health disorders and addictions (Green et al., 2017), and cigarette smoking together with alcohol use is an established risk factor for suicide (Hawton & van Heeringen, 2009; Li et al., 2012). However, studies that have adjusted for alcohol intake still find an independent association between smoking and suicide (Li et al., 2012).
Smoking is also more common among segments of the population who, for various reasons, are at increased risk of suicide. These demographics include individuals with higher levels of life stressors and fewer coping skills and other resources (e.g., lower SES, less education, or unemployed).
Green and colleagues (2017) hypothesize, for example, that: “If the initiation of smoking starts at a young age when an individual is developing coping skills, tobacco use can quickly become the only mechanism used to cope as it provides instant relief of negative emotions” (p. 839).
Regardless of specific causation, cigarette smoking is a risk factor for suicidal behavior and death. In fact, data from a very large longitudinal study conducted in the U.S. found that the relative risk of death associated with smoking was 4.4 for women and 3.2 for men, after adjusting for factors including age, race, education level, and daily alcohol intake (Green et al., 2017; Sareen et al., 2015).
Miller and colleagues (2000) also found that Army personnel who smoked were more likely to have risk factors in common with depression and suicide, such as being White, heavy drinkers, and less educated, among other things. When they controlled for these factors, however, there was still “a strong, positive, dose-related association between smoking and completed suicide” (Miller et al., 2000, p. 1062).
There is an increasing body of evidence that quitting smoking can reduce suicide risk, though not to the level of never smokers (Leistikow & Shipley, 1999; Li et al., 2012).
Military and Veteran Populations
The U.S. Department of Defense recently released its Annual Suicide Report for the calendar year 2020. The report shows an increase in the total number of suicides between 2019 and 2020, and this increase was not only among active-duty soldiers, but also among reservists and the National Guard (DoD, 2021).
In 2020, there were approximately 29 suicide deaths per 100,000 active-duty troops, up from approximately 26/100,000 in 2019 and 25/100,000 in 2018, which was at that time considered an all-time high (DoD, 2018; LaPorta, 2019). Among the services, the Army showed the highest rate, with 36.4 deaths per 100,000 soldiers (DoD, 2021).
High rates of suicide have also been found among military veterans. Veterans are 1.5 times more likely to die by suicide than non-veterans. Female veterans are particularly at risk, with a suicide rate 2.2 times higher than that of non-veteran adult women (Shane, 2019).
Other risk factors among military and veteran populations include early separation from service, transition to civilian life, recent deployment, lower rank, younger age, clinical depression, comorbidity (Fazel & Runeson, 2020; Ravindran et al., 2020) and recent discharge from a psychiatric hospital (Kessler et al., 2015).
U.S. veterans with opioid use disorder have a rate of suicide six times greater than the general population. Having an opioid use disorder more than doubles the risk of suicide in female veterans, and increases the risk of suicide by 30% in male veterans, compared to veterans who do not have an opioid use disorder (Oquendo & Volkow, 2018).
Another risk factor among veterans and military personnel is access to lethal means. Over 60% of U.S. military suicides occur at home and involve a personally-owned firearm (Myers, 2021; Pruitt et al., 2017). The firearm suicide rate among veterans is 1.5 times that among non-veterans (Everytown Research & Policy, 2021; U.S. Department of Veterans Affairs, 2018).
A recent study found that military personnel with suicidal ideation were 53% less likely to store firearms in a safe manner than those with no such history. In this same study, military personnel with recent thoughts of death or self-harm were 74% less likely to store their firearms safely (Bryan et al., 2019; Theis et al., 2020). This represents a challenge for clinicians given the proportion of military veterans who have legal access to firearms.
Researchers have been looking for better ways to identify military personnel at imminent risk.
One recent study, for example, looked at data from a large sample of U.S. Army soldiers who had made a suicide attempt within 30 days of first medical documentation of suicidal ideation. They found that certain groups of enlisted soldiers, specifically women and combat medics, are at heightened risk of rapid transition from ideation to attempt.
Soldiers who had been diagnosed with a sleep disorder on the same day as they were documented to have suicidal ideation were also found to have increased suicide vulnerability (Herberman Mash et al., 2021).
Race, Ethnicity, and Culture
Suicide is sometimes erroneously thought of as only a “white man’s problem.” White males account for about 70% of all suicides in the United States. The suicide rate for white individuals in the U.S. is 18 per 100,000 persons compared to an overall suicide rate of 14.2 per 100,000.
However, the suicide rate is actually highest in the American Indian/Alaskan Native population and is a significant problem in other racial and ethnic groups (SPRC, 2020).
In addition, American Indian/Alaskan Native, Asian American, Black/African American, and Hispanic suicides are often undercounted, either due to medical examiners misclassifying the deaths or families not wanting to report the suicide due to stigma (Dennis, 2018).
American Indian/Alaskan Native Populations
American Indian and Alaskan Native (AI/AN) populations have the highest suicide rate of all racial and ethnic groups in the U.S., with 22.1 suicides per 100,000 persons in 2018. While suicide rates in the overall U.S. population are highest among middle-aged adults, suicide rates in AI/AN populations are highest among adolescents and young adults (SPRC, 2020).
There is significant cultural and ethnic heterogeneity among AI/AN populations. There are currently 574 federally recognized tribal nations and Alaska native villages, with members speaking over 200 languages (National Congress of American Indians, 2020). AI/AN have the highest poverty rate of any racial and ethnic group in the U.S.
While the rate of mental disorders, and especially those associated with suicide, are high in this population, mental health treatment rates are low (APA, 2020). Reasons may include a lack of available services, lack of culturally competent care, economic barriers, and stigma (SAMHSA, 2010).
Potential risk factors for suicide in the AI/AN population include higher rates of alcohol use disorder, substance use disorder, and post-traumatic stress disorder, as well as stressors related to poverty discrimination, racism, and historical trauma (SAMHSA, 2010). SAMHSA has published a guide for understanding suicide within AI/AN communities and promoting culturally sensitive practices in these communities. Find access to this manual.
Asian American and Pacific Islander Populations
The Asian American and Pacific Islander (AA/PI) population in the U.S. is very diverse, consisting of approximately 50 subpopulations and over 100 languages. Studies have found that only 30% of this population is fluent in English, presenting a significant barrier to accessing mental health services (APA, 2020).
Other obstacles to accessing mental health care include stigma, especially among first-generation immigrants. In AA/PI cultures, having a mental illness can be a source of shame and weakness. Structural barriers also exist, including lack of cultural competency among service providers and a lack of research specific to these populations.
These factors may contribute to the finding that the AA/PI population is the least likely of all racial and ethnic groups in the U.S. to seek mental health care (APA, 2020).
With respect to suicide, the suicide rate among AA/PI populations is highest among the elderly and the young, in contrast to the overall U.S. population, where suicide peaks in middle-aged adults. The suicide rate among AA/PI young adults has also been on the rise, according to recent CDC data (SPRC, 2020; SAMHSA, 2018).
The World Health Organization and Each Mind Matters: California’s Mental Health Movement have highlighted educational resources and outreach materials about suicide in Bengali, Chinese, Hmong, Khmer, Korean, Lao, Mien, Tagalog, Vietnamese, and Japanese, which can be shared with patients.
Black/African American Populations
Black/African American communities make up about 13% of the U.S. population. Only one-third of Black/African American individuals who are in need of mental health care receive it. They are less likely to be offered evidence-based medicines, psychotherapy, and other outpatient services compared to the general population.
Black/African American individuals with psychotic disorders (e.g., schizophrenia, bipolar disorder) are also more likely to be incarcerated than those with these conditions in other racial and ethnic groups (APA, 2020). In addition to stigma and structural racism, other barriers to treatment in Black/African American communities include lack of culturally-competent care, lack of insurance, and lack of trust in the health care system (APA, 2020).
Over the past few decades, suicide attempts among Black/African American adolescents have increased significantly (Lindsey et al., 2019). Black/African American high school youth are more likely than the overall high school youth population to have attempted suicide in the past year and their suicide attempts are more lethal (SPRC, 2020).
Moreover, a recent study also found that the suicide death rate of black youth also increased significantly between 2003 and 2017 for both genders and all age groups (5-11, 12-14, and 15-17); the greatest percentage increase was among girls (6.6%) and those in the 15-17 year group (4.9%) (Sheftall et al., 2021).
Congress asked the Department of Health and Human Services (HHS) to report back on why preadolescent Black children are dying by suicide at nearly twice the rate as preadolescent white children.
In response, HHS conducted a study of 2,266 non-Hispanic Black and white youth aged 10 to 17 who had died by suicide between 2014 and 2017. They found that the Black youth were more likely than the white youth to have a crisis in the two weeks prior to their death and to have a family relationship problem, argument, or conflict (U.S. Department of Health and Human Services, 2020).
The study also found that Black youth were more likely than white youth to have made a previous suicide attempt (U.S. Department of Health and Human Services, 2020).
This is consistent with recent research, which found an approximately 80% rise in suicide attempts among Black adolescents over the last 30 years, whereas the prevalence of attempts among other racial and ethnic groups did not significantly change (and even declined in some cases) during this same time period (Xiao et al., 2021).
Despite this rise, the Black suicide decedents in the HHS study were less likely than white suicide decedents to have a known mental health problem, current depressed mood, history of suicidal thoughts or plans, and past or current treatment for mental illness.
The fact that Black youth are less likely to have to have had mental health treatment prior to their death, but more likely to have a history of suicide attempts, is especially concerning, as it suggests significant disparities in access to and/or utilization of available mental health resources.
A New York Times article titled, “Why Are More Black Kids Suicidal? A Search for Answers,” discusses a number of reasons explaining the low treatment rate of depression in Black adolescents. For one, there is a shortage of mental health professionals in Black communities, and especially mental health providers of color (Caron, 2021).
According to the American Psychological Association’s Center for Work Force Studies, only 4% of psychologists were Black/African-American in 2015 (Lin et al., 2018). Stigma is also a barrier. There can be shame in having depressive symptoms and seeking out treatment, even when such treatment is available (Caron, 2021; Jon-Ubabuco & Champion, 2019).
Mitigating suicide risk in Black youth will necessitate a full-scale approach. The HHS report recommends early identification and treatment of mental health issues, including school-based screening, interpersonal problem-skills training, and family-based interventions.
This must occur in combination with strategies that address systemic issues, such as health care disparities, racism, and other social determinants of health. Access the full report: African American Youth Suicide: Report to Congress.
Hispanic and Latino Populations
The U.S. Hispanic/Latino population is also very diverse, and includes people from throughout Latin America and other Spanish-speaking countries.
Research on suicide in the Hispanic population is limited, but suggests that mental health treatment in this population is low. In 2018, Hispanic adults were half as likely to receive mental health treatment as non-Hispanic white adults. Barriers to treatment in this population include a shortage of bilingual or Spanish-speaking mental health professionals, low rates of insurance coverage, and stigma surrounding mental illness (APA, 2020).
In 2017, suicide was the second leading cause of death for Hispanics aged 15 to 34. CDC data show that Hispanic adolescents have high rates of suicide attempts, especially girls. Suicide attempts for Hispanic girls, grades 9-12, were 40 percent higher than for non-Hispanic white girls in the same age group, in 2017 (CDC, 2019; HHS, Office of Minority Health).
Culturally Competent Care
Lack of cultural understanding by health care providers may contribute to treatment disparities in racial and ethnically diverse groups. The American Psychiatric Association’s Cultural Competency webpage has a wealth of information about working with diverse populations. Access this webpage.
Primary Care Patients
Approximately 4 out of 5 persons who die by suicide will have seen a healthcare provider in the preceding year, though 55% will not receive a mental health diagnosis.
One study of insured patients also found that nearly half will have made a healthcare visit within 4 weeks of suicide death, but only 24% of those who made a visit had a mental health diagnosis within that 4-week period (Ahmedani et al., 2014).
These findings are consistent with a systematic review, which found that, on average, 45% of those who die by suicide had contact with a primary care provider within 1 month of their suicide (Luoma et al., 2002).
A long list of physical health conditions has been associated with suicide death. These conditions include asthma, cancer, chronic pain, COPD, coronary artery disease, diabetes, spinal disk disorders, stroke, and traumatic brain injury.
In general, chronic illness, terminal illness, and functional impairment places patients at greatest risk (Racine, 2018; Schreiber & Culpepper, 2020; Tang & Crane, 2006). Persons with these conditions can be assessed for suicide so as to inform a treatment plan (Jacobs, 2000).
In addition to these physical health conditions, other conditions may warrant screening for suicide risk. These include having a prior suicide attempt, psychiatric history, substance use disorder, family history of suicide or violence, and symptoms such as irritability, agitation, and aggression.
Inquiring about suicidal ideation may also be indicated when patients mention that they feel alone, that they experienced a recent loss leading to humiliation, shame, or despair, or that they had been exposed to a suicide (Suicide Prevention Resource Center, 2021).
At this time, however, there is no requirement for universal screening for suicidal ideation in primary care settings, adult nor pediatric. In 2020, The U.S. Preventative Services Task Force reviewed evidence for suicide ideation screening. They felt there needed to be additional research into the risks and benefits of screening as well as the effectiveness of interventions for populations experiencing suicidal ideation before making a recommendation (Holcomb et al., 2022).
The Joint Commission, which certifies and accredits healthcare organizations and programs in the United States, requires that patients age 12 or above who are being evaluated or treated for behavioral health conditions in an accredited facility be screened for suicidal ideation, but they do not require universal screening (Joint Commission, 2018).
In a recent article, Holcomb and colleagues (2022) discuss the challenges faced by primary care pediatricians who are seeing increasing numbers of adolescents experiencing suicidal ideation in their practices.
The authors found that nearly 5% of a large national sample of adolescents reported experiencing suicidal ideation at least several days over the two weeks prior to their well-child visit. These adolescents who endorsed experiencing suicidal ideation also reported a high rate of past suicide attempts (20.5%) and had significant impairment in other psychosocial domains (e.g., depression, anxiety, attentional difficulties, conduct problems).
The authors go on to discuss the implications for pediatric practice. They argue that while most patients who screen positive for suicidal ideation on screening instruments are not at imminent risk of suicide, they are still experiencing significant psychological distress and could benefit from further assessment and management (Holcomb et al., 2022).
In other words, “The approximately five percent of teenagers identified by the PSC and PHQ-9 should be treated almost like they have a chronic disease…It’s a group that needs care management and ongoing attention, which pediatricians already do with other chronic conditions,” according to Dr. Michael Jellinek, one of the study authors (Mainey, 2022).
A key factor in reducing suicidal behavior will be diagnosing and treating major depression in primary care. There is evidence that training primary care providers on how to recognize and treat depression decreases suicidal ideation and suicide death in patients (Mann et al., 2005; Suicide Prevention Resource Center, 2021).
In addition to identifying and managing depression and suicidality, suicide prevention in primary care settings involves educating staff and patients about suicide warning signs, safety planning, and means restriction. Having a pre-established protocol regarding referral for hospitalization and evidence-based treatment in such cases is useful (Suicide Prevention Resource Center, 2021).
Please note that the National Suicide Prevention Lifeline is available 24/7 for patients who are in a suicidal crisis or who may be experiencing emotional distress.
The Suicide Prevention Resource Center website has a toolkit available to help primary care practices. The toolkit includes information on assessment, safety planning, referral, billing, and other resources to help primary care providers with suicide prevention. Access the online version or the free pdf.
Health Care Providers
Physicians are also at risk for suicide. The rate of suicide among physicians is 28-40/year per 100,000, which is 2-4 times the rate in the general population. In fact, according to a recent presentation at an American Psychiatric Association conference, physicians were reported to have the highest rate of suicide of any profession.
The rate of suicide among physicians is even higher than among military personnel. The rate is also high among other health care professionals, including nurses, dentists, and veterinarians (Hawton et al., 2011; Tomasi et al., 2019).
Although depression appears to afflict physicians at rates similar to that of the general population, the suicide rate is significantly higher in physicians, and especially among women. Unlike the gender gap in the general population, female physicians have a death rate approximately equal to that of their male colleagues.
Having knowledge of and access to lethal substances may account for the higher rate of suicide death among doctors (Brooks et al., 2018; Dong et al., 2020). A recent meta-analysis also found a relatively high lifetime prevalence of suicidal ideation among physicians (Dong et al., 2020).
Medical students and physicians experience significant stress, including high demands, competitiveness, long hours, and lack of sleep. These may contribute to alcohol and substance abuse, which are risk factors for suicide. Between 10% and 15% of physicians report alcohol or substance abuse compared with 9% of the general population (Baldisseri, 2007).
Stigma is an obstacle to seeking treatment. In one study of 954 medical students who screened positive for depression, only 15% sought psychiatric treatment (Hoffman & Kunzmann, 2018; Rotenstein et al., 2016). Half of women physicians completing a Facebook questionnaire reported meeting criteria for a mental disorder, but said that they were reluctant to seek professional help because of the fear of stigma (Gold, 2016).
The American Foundation for Suicide Prevention has a collection of resources for physicians who may be dealing with professional burnout, depression, and suicidal feelings, which can be accessed here.
The current COVID-19 pandemic is presenting additional mental health challenges to health care workers, including suicide (Knoll et al., 2020). Read a recent opinion piece on the topic, which contains suggestions for how you might be able to mitigate suicide risk among your medical colleagues.
The COVID-19 pandemic is emotionally stressful, and can be especially distressing for those already struggling with symptoms of depression and anxiety. According to recent data, Americans are reporting increased symptoms of depression, anxiety, and fear (Holland, 2020, MHA, 2020). COVID-19 is increasing the likelihood of serious mental illness, which are risk factors for suicide (Geller & Abi Zeid Daou, 2020).
Suicidal ideation is one of the most concerning symptoms of depression. The CDC recently reported that more than two times as many respondents had seriously considered suicide in the 30 days preceding their June 2020 survey than in the 12 months preceding a survey they had administered in 2018 (10.7% in 2020 vs. 4.3% in 2018).
The rate of suicidal ideation during the COVID-19 survey was particularly high among certain groups, notably young adults aged 18-24 years (25.5%), Hispanic individuals (18.6%), non-Hispanic Black individuals (15.1%), unpaid caregivers (30.7%), and essential workers (21.7%) (Czeisler et al., 2020).
Youth between the ages of 12 and 17 also made more visits to the Emergency Department for suspected suicide attempts during the pandemic than they did before the pandemic. While suicide-related visits to emergency departments had decreased early in the pandemic likely due to the issuance of shelter-in place orders, they began to increase in May 2020 and soon significantly surpassed pre-pandemic levels.
According to CDC data, suspected suicide attempts were 2.4 times higher in the spring of 2020, 1.7 times higher in the summer of 2020, and 2.1 times higher in the winter of 2021 than they were during the same periods in 2019. This elevation in suspected suicide attempts occurred especially among adolescent girls (Yard et al., 2021) and among those with no prior history of psychiatric problems (Ridout et al., 2021).
It is not yet known how COVID-19 will specifically impact suicide rates and it may take several years before data are available. However, there are some communities already seeing a spike in suicide rates in their counties (Vernachio, 2020).
While the overall number of suicides in the U.S. decreased by 5% between 2019 and 2020, this decline was accompanied by an increase in the number of suicides among people of color and an increase in the number of overdose deaths (Rabin, 2021).
It is unclear if the decline in the number of suicide deaths in 2020 is a consequence of the pandemic or a continuation of a downward trend in suicides after suicides crested in 2018. The Department of Defense also reported an increase in the number of suicides in the military, but the DoD saw it as continuation of a current, distressing, upward trend and did not attribute it specifically to the pandemic (DoD, 2021).
Dr. Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention, published an published an article in JAMA Psychiatry, which discusses how increased suicide rates are not an inevitable outcome of the pandemic. Rather, there are specific steps that can be taken now to reduce suicide risk both during the pandemic and in the future.
These steps include not only increasing social connectedness and access to mental health care, but also addressing issues such as domestic violence, alcohol and drug use, financial strain, access to firearms, and irresponsible media reporting.
As Dr. Moutier explained at the 2020 National Stop A Suicide Today Town Hall, the pandemic could serve as a potential positive catalyst for change, with some “silver linings,” such as normalizing the dialogue surrounding mental health experiences and increasing access to telehealth services.
How Clinicians Can Help Mitigate Risk During the Pandemic
- Screen patients for depression and ask about suicide risk
- Develop or update safety plans for patients with suicidal ideation
- Help connect people with family and loved ones
- Follow telehealth guidelines
- Educate people about the warning signs for suicide
- Push for increased mental health services, especially for underserved populations
- Prioritize self-care for patients, families, and yourself
Resources for Clinicians
The Zero Suicide Initiative has compiled a compendium of resources for health and mental health clinicians on providing suicide care during the COVID-19 pandemic. Access these resources.
In addition, the American Psychiatric Association has published an article about providing care for patients with serious mental illness during the COVID-19 pandemic (Geller & Abi Zeid Daou, 2020).
This guide includes practical information, including information specifically relevant to inpatient psychiatric hospitals. Access this article.