Suicidal Thoughts

If you or someone you know is considering suicide, call 1-800-SUICIDE.

Suicidal thoughts are troubling, especially when accompanied by depression, other mental illnesses, alcohol or drug abuse, or plans for suicide. This situation demands immediate evaluation. These thoughts can indicate serious illness.

The critical distinction is between a person’s thoughts regarding death and suicide, and actually wanting to die. When doctors hear that someone wants to die, they refer to these thoughts as suicidal ideation and divide them into 2 categories.

• Suicidal ideation can be active and involve a current desire and plan to die.

• Suicidal ideation can be passive, involving a desire to die but without a plan to bring about one's death.

If a person has an actual desire to die (in either form of suicidal ideation), he or she must seek immediate medical attention.

Many people experience suicidal thoughts at some time in their lives.

• In otherwise healthy people, such thoughts are often brought about by sudden, unexpected change in life circumstances.

• Suicidal ideation is part of many mental illnesses, including depression, schizophrenia, and drug or alcohol abuse.

• Strong evidence exists that depression—and many other forms of mental illness—can be passed from parent to child and that a tendency toward suicidal ideation and suicide is likewise inherited.

A person is either experiencing thoughts about committing suicide or not. Almost as important are the symptoms that may accompany these thoughts.

• Depression: Suicidal thoughts may be present if a person is experiencing depression. Depression can be easily assessed.
  • Others may note that depressed people seem "down" or upset.

  • Most depressed people report sleep disturbances—either an inability to fall asleep or an inability to sleep through the night.

  • Depressed people often speak of feeling hopeless or helpless. They seem unable to experience any feelings of happiness, even when participating in activities they normally enjoy.

  • Many of these people experience either a rapid weight gain or weight loss along with their depression.

  • They may seem inattentive, and their performance at work or school may suffer.

  • They may appear listless and even complain of feeling "down" or depressed.

  • Depressed people are often burdened with a tremendous sense of guilt. To an outside observer, this guilt often seems unwarranted, but to the depressed person, it seems deserved.

• Alcohol or drug addiction: If someone has an ongoing problem with alcohol or drug addiction, he or she is at increased risk to become actively suicidal.
  • Drug and alcohol problems generate other circumstances in a person’s life, which may worsen depression.

  • Divorce, loss of job, legal trouble, and financial difficulties often grow from a dependence on alcohol or drugs and can bring about thoughts of suicide.

• Mental illness: For someone with a diagnosed mental illness such as schizophrenia or someone who has attempted suicide in the past, thoughts of suicide take on a new dimension of importance.

A call to the health care provider or to 911 is warranted when someone admits to suicidal ideation. That is, if someone actively wishes his or her own death, then evaluation by a medical professional is absolutely essential.

Any form of suicidal ideation—that is, actively wishing your own death—should prompt immediate evaluation by a medical professional.

By the time someone admits to having a thought or plan to end one's life, the person may have already initiated the plan.

• It is not uncommon for a person with suicidal ideation to be treated in the emergency department for having taken an overdose but have told no one. 

• Guessing about a person's true intentions when suicidal ideation is a concern is dangerous and wrong.

Professionals often speak of a "suicidal gesture."

• This occurs when a person harms himself or herself in such a way as to bring sympathy but not death.

• Even if you believe a person is "doing it just for attention," you must not rely on this feeling.

Many people make gestures that are unintentionally lethal.

• For instance, someone may take an overdose of acetaminophen (Tylenol) in order to gain sympathy, not understanding that an overdose of Tylenol can be fatal.

• It is not your job as a concerned friend or family member to evaluate the intent of the person with suicidal ideation. Your job is to get the person to the hospital as soon as possible.

The assessment of people with suicidal thoughts is far from an exact science.

• If a person is evaluated by the primary health care provider, he or she may be instructed to go immediately to the emergency department for further evaluation.

• If evaluated in the emergency department, the emergency physician may enlist the help of a psychiatrist for more expert diagnosis and treatment.

The assessment, whether in the medical office or emergency department, includes the following parts.

Medical interview: A person who is having thoughts of suicide is interviewed extensively by medical professionals. Questions such as these are asked:

• Have you swallowed any medicines or drugs?

• What plan do you have for ending your life?

• What circumstances in your life brought you to the point of suicide?

• Have you ever attempted suicide in the past?

• What is your family history of mental illness or suicide, if any?

• Have you used alcohol or drugs?

• Have you recently experienced any emotional loss (such as the death of a loved one or a divorce)?

• Do you have any medical illnesses or history of surgery?

• Are you currently taking any herbal, over-the-counter, or prescribed medicines?

Mental status: This is a crucial part of the history is the mental status examination.

• This is a formalized series of questions and commands designed to point toward any psychiatric or neurologic problems, such as depression or schizophrenia.

• The questions may seem silly or insultingly easy, but they are designed to highlight disordered thinking and disorientation that could signal mental illness.

Physical examination: The medical professional performs a head-to-toe physical examination.

• The person's strength, sensation, coordination, reflexes, and ability to walk and balance are checked.

• Depending on the person’s age and health status, this may take anywhere from a few minutes to over 20 minutes.

• Any abnormalities may require further evaluation because certain disease states and certain medicines can actually cause depression and lead to suicidal thoughts.

Lab tests: The decision to order lab tests is based on the findings of the interview and physical examination.

• No lab test is available for depression, and no lab test is available to tell if someone is serious about committing suicide.

• Any suggestion of medical illness, drug or alcohol intoxication or overdose, or poisoning usually mandates lab tests.

• Blood and/or urine may be checked for drug and alcohol levels.

In some cases, x-rays or CT scans or an ECG may be ordered.

|Self-Care at Home|

For the otherwise healthy person with no signs of depression, mental illness, or drug or alcohol abuse, fleeting thoughts about death or suicide are usually harmless. However, any current desires to die make home care completely inappropriate.

If anyone—including the suicidal person—has concerns that the person might be depressed or have other difficulties, then home care is not appropriate.

A concerned friend or partner should inquire directly about thoughts of suicide.

• Contrary to conventional wisdom, asking about suicidal thoughts or plans does not "put the idea in the person’s head."

• If you are concerned that someone may be depressed or suicidal, then ask in a direct and caring manner.

• You might simply say, "You seem down to me, and I'm concerned. Is everything all right? Are you experiencing thoughts about death or suicide?"

|Medical Treatment|

The treatment for suicidal thoughts might range from gentle reassurance to admission to the hospital.

• In some cases, the person is sent home with instructions to return if the thoughts become persistent or symptoms of depression become evident.

• In this case, follow-up with a mental health professional is usually arranged within 48 hours.

• An anti-anxiety medication or even an antidepressant may be started right away.

• If the person’s suicidal thoughts are believed to be of a dangerous nature, follow-up is likely to be immediate with admission to the hospital.

If someone is admitted to the hospital because of suicidal thoughts, he or she undergoes extensive evaluation by a psychiatrist and often is started on medication and scheduled for follow-up counseling.

From the physician's perspective, suicidal thoughts are to be taken seriously and evaluated thoroughly. Predicting suicide is difficult.

• People who actually commit suicide are usually terribly depressed.

• They often have alcohol or drug abuse problems.

• Many are diagnosed with schizophrenia—a serious mental illness.

• Many commit suicide in response to difficulties in their lives.

• By the same token, most depressed people, people with drug or alcohol problems, and those with schizophrenia never attempt suicide.

|Follow-up|

Persons who actually attempt suicide need close psychiatric follow-up and counseling.

• This may seem obvious, but many suicidal people do not get good follow-up treatment and often end up thinking of suicide (or even attempting it) again.

• Follow-up usually consists of counseling and medication for depression.

Keeping follow-up appointments in the case of suicidal thoughts is so important that the referring health care provider will likely contact the consultant before discharging the person from the office or the emergency department.

|Prevention|

Suicidal thoughts can be prevented by following the recommendations of your health care provider. Whether treatment is recommended or medicines and counseling are suggested or not, following through on treatment is the best means of prevention.

Suicidal thoughts can be frightening, and they can indicate a serious illness. People with depression or other forms of mental illness are not "weak-willed." They have a real disease. Real medicines are usually successful in treatment.

If you feel that someone is depressed, ask. If you are concerned that someone might be considering suicide, ask. If someone volunteers to you that they are thinking about suicide, please listen. It might be the only cry for help they utter.

|Outlook|

The outcome for a person experiencing suicidal thoughts depends on the cause of the thoughts.

• The occasional thought about death without the worrisome symptoms can be ignored.

• Many people having suicidal thoughts are depressed. For those diagnosed with depression, the prognosis is good for a full recovery with the aid of antidepressant medication and counseling.

• For those with alcohol or drug problems, recovery can be long and difficult, but can be done.

• Those with more severe mental illnesses such as schizophrenia may hope for great improvement in their disease with the aid of medication and regular psychiatric care.

|Support Groups and Counseling|

Many support groups exist for people who are thinking of suicide. If you or someone you know is considering suicide, call 1-800-SUICIDE.

• Befrienders International: To find a local suicide prevention hotline, log on to the Web site of this suicide prevention group.
  
  
• Depression and Related Affective Disorders Association (DRADA) (410-955-4647)
  
  
• Mood Challenge Support Group (309-671-8000)
  
  
• Mood Disorders Support Group, Inc (212-533-MDSG)
  
  
• National Alliance for Research on Schizophrenia and Depression (800-829-8289)
  
  
• National Depressive and Manic-Depressive Association (800-826-3632)
  
  
• National Foundation for Depressive Illness (800-239-1265)

|Web Links|

National Alliance for the Mentally Ill (NAMI)

National Institute of Mental Health, Bipolar Disorder 

National Mental Health Association (NMHA)

Pendulum Resources

alcohol abuse, depression, drug abuse, drug overdose, mental illness, poisoning, substance abuse, suicidal gesture, suicidal ideation, suicide, suicide attempt, thoughts of death, thoughts of dying, thoughts of killing myself, want to kill myself, suicidal thoughts

Author: John Shields, MD, Staff Physician, Department of Emergency Medicine, Denver Health Medical Center.

Coauthor(s): Erik D Barton, MD, MS, Associate Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Jeter (Jay) Pritchard Taylor III, MD, Vice-Chief, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina.