Suicidal Behavior

Statistics on suicidal behavior are based mainly on death certificates and inquest reports and underestimate the true incidence. To provide more reliable information in the United States, the Centers for Disease Control and Prevention (CDC) established a state-based system called the National Violent Death Reporting System (NVDRS), which collects facts about each violent incident from various sources to provide a clearer understanding of the causes of violent deaths (homicides and suicides). The NVDRS is now in place in all 50 states, the District of Columbia, and Puerto Rico.

In the United States, suicide had been the 10th leading cause of death for several decades until 2020, when COVID-19 became the third leading cause of death and displaced suicide from the top 10 (1, 2 ). The US suicide rate increased from 1999 through 2018 by an overall 36% (from 10.2 to 14.2/100,000 people per year), followed by 2 consecutive years of decreasing rates in 2019 and 2020. US 2021 suicide data, unfortunately, showed a 4% increase from 2020 to 2021 (2, 3). Since suicide is known to be a multifactorial, complex health outcome, the reasons for changes in population rates are challenging to identify, but they are thought to be related to factors such as cultural attitudes toward mental health and help-seeking, access to mental health care, access to lethal means, and numerous other influences. External societal trends and personal experiences are thought to interact with internal, individual risk factors such as having experienced trauma or having a genetic predisposition that can increase risk for suicide (3).

In 2021, the age groups with higher suicide rates were adults ages 25 to 34 and 75 to 84, but rates were highest for adults older than 85. The highest suicide rate across racial and ethnic groups by age is found among American Indian youth (2). However, in terms of overall burden of suicide, White males, who make up approximately one third of the US population, account for 7 in every 10 suicides in the United States. Emerging data also indicate increasing suicide rates among Black, Hispanic, and Asian American populations (4). For current statistics on suicide, see the data provided by the American Foundation for Suicide Prevention.

In the 1990s, youth suicide rates decreased after more than a decade of steady increase, only to start climbing again in the early 2000s due to an alarming increase in suicide deaths by gun. Numerous influences are likely related to the increasing trends in suicide rates among children and adolescents, including the following (5):

• Unaddressed mental health conditions (including major depressive disorder, bipolar disorder, substance use disorders, psychosis, eating disorders, attention-deficit/hyperactivity disorder [ADHD], anxiety disorders, and/or trauma)

• Health conditions such as traumatic brain injury or autism spectrum disorders

• Adverse childhood events (including abuse, neglect, loss)

• Experiences of trauma or loss (including unstable home environment; growing up with a parent with mental illness; exposure to peer suicide and/or a relative who died by suicide; experience of bullying or discrimination based on race, gender, or sexual orientation)

Research on the role of social media is evolving and so far reveals a complex and variable influence of social media use, ranging from detrimental effects on mood, sleep, and suicidal ideation to positive interpersonal connectedness for some people, which can actually be protective (6). (See also Etiology). Additional data also suggest a possible effect of boxed warnings issued by regulatory agencies about the increased risk of suicidality in children and adolescents associated with antidepressant use, which may have resulted in decreased treatment of major depressive disorder (7, 8).

Male deaths by suicide outnumber female deaths approximately 2.5:1 to 4:1 globally and nearly 4:1 in the United States. The reasons are unclear, but possible explanations include

• Males are less likely to seek help when they are distressed.

• Males have a higher prevalence of alcohol use disorder and substance use disorder, both of which give rise to impulsive behaviors.

• Males tend to be more aggressive and use more lethal means when attempting suicide.

• The number of suicides in males includes suicides among military personnel and veterans, where there is a higher proportion of males to females.

In terms of the spectrum of suicide-related experiences, an estimated 14 million Americans experience suicidal ideation, 1.4 million American adults have made a suicide attempt, and just under 50,000 die by suicide each year. Suicidal ideation is a fairly common experience in the general population and more common in clinical samples. Of those who consider suicide, far fewer act on suicidal thoughts or impulses. Among people who survive even medically serious suicide attempts, more than 90% do not go on to die by suicide. From a life span perspective, adolescents and young adults have the highest incidence of suicidal ideation; females attempt suicide more than males, but males die by suicide at 3 to 4 times the rate of females. Among older adults, while suicidal ideation is less common, 1 in 4 suicide attempts end in death.

A suicide note is left by about 1 in 6 people who complete suicide. The content may indicate clues regarding the factors that led to the suicide (eg, psychiatric illness, hopelessness, cognitive constriction and narrowing of perceived options for coping, sense of being a burden to others, and sense of isolation). The intersection of these and other life stressors or losses may precipitate suicide.

Suicide contagion refers to a phenomenon in which one suicide seems to beget others in a community, school, or workplace. Highly publicized suicides may have a very wide effect. Affected people are usually those already vulnerable. Humans are social creatures prone to imitation of one another, and adolescents are more likely to engage in imitation than adults because of their stage of psychological and neurological development. It is estimated that contagion is a factor in 1 to 5% of all adolescent suicides.

Contagion can occur by exposure to a peer who attempts or dies by suicide, by widespread media coverage of a celebrity’s suicide, or by graphic and/or sensationalized portrayal of suicide in popular media. Conversely, media coverage with positive messaging about a suicide death can mitigate the risk and/or impact of suicide contagion for vulnerable youth. Positive-themed suicide prevention messaging typically involves portraying mental health struggles as part of life and human health experience with no stigma related to seeking help and treatment. After a suicide has occurred, positive messages in a school or workplace should communicate clearly about the tragic loss of a community member, express support for the grieving community, and provide resources for support. The language a leader uses to discuss suicide, whether in writing or at in-person meetings, for debriefing the loss is important. For more detailed information on communication and templates for written communication, see the After A Suicide Toolkits freely available from the American Foundation for Suicide Prevention ( afsp.org ).

Suicide contagion can also spread in schools and workplaces, which are important settings for implementing and following postvention guidelines to prevent future suicides.

Other categories of suicide are rare. These include

• Group suicides

• Murder/suicides

• "Suicide by cop" (situations in which people act in a way, for example, brandishing a weapon, that prompts law enforcement officers to act with deadly force)

Suicide is a complex health-related event that involves a set of genetic, environmental, and psychological and behavioral factors. Psychological autopsy studies clearly show that in each instance of suicide, decedents were experiencing multiple risk factors for suicide. Death by suicide is much more common among people with a psychiatric illness than among age- and sex-matched controls (1). In some studies, almost 90 % of people who die by suicide have a diagnosable mental health condition at the time of their death (2). (See table Frequency of Mental Health Disorders in Suicide.)

One of the most common, potent, and remediable risk factors for suicide is depression.

For patients with depression, suicide risk can increase during periods when depression is more severe, and when several other risk factors converge. Also, suicide appears to be more common when severe anxiety, impulsivity, substance use, and sleep problems are part of major depression or bipolar depression. Risk of suicidal thoughts (and, rarely, attempts) may increase in younger age groups after antidepressant drugs are started (see Treatment of depression and risk of suicide and Suicide risk and antidepressants). Effectively treating depression with medications and/or some form of psychotherapy is considered an effective way to reduce suicide risk overall.

Other risk factors for suicide include the following:

• Most other serious mental health conditions

• Previous suicide attempts

• Personality disorders (eg, borderline personality disorder)

• Impulsivity and aggression

• Traumatic childhood experiences

• Family history of suicide and/or psychiatric conditions

• Use of alcohol, illicit drugs, and prescription analgesics

• Serious or chronic physical health conditions (eg, chronic pain, traumatic brain injury)

• Times of loss (eg, death of family or friends)

• Relationship conflict (eg, divorce)

• Work disruption (eg, unemployment)

• Periods of career transition (eg, changing one's military status from active duty to veteran status or retirement)

• Financial stress (eg, economic downturns, underemployment)

• Bullying or other humiliating experiences (eg, cyberbullying, social rejection, discrimination, occupational or legal problems)

(See table Risk Factors and Warning Signs for Suicide.)

People with schizophrenia die by suicide at a much higher rate compared to the general population, with as many as 10% of patients with schizophrenia dying by suicide. Drivers of suicide risk among people with schizophrenia include early phase illness, depressive episodes, hallucinations, lack of access to or nonadherence to effective treatment, disability, hopelessness, and akathisia. Other well-known psychosocial risk factors for suicide include relationship disruption, unemployment, and loss.

Alcohol and illicit drugs may increase disinhibition and impulsivity as well as worsen mood. Between 30% and 40% of people who die by suicide have consumed alcohol before the attempt, and about half of them were intoxicated at the time. Younger people, who are generally more prone to impulsive behavior , are particularly susceptible to alcohol's effects; moderate levels of intoxication can result in their using more lethal suicide methods (3). However, people with an alcohol use disorder are at increased risk of suicide even when they are sober.

Serious physical health conditions, especially those that are chronic and painful, contribute to about 20% of suicides in older patients. Recently diagnosed or new-onset physical health conditions can also increase suicide risk (eg, diabetes, seizure disorder, pain conditions, multiple sclerosis, cancer, infection, HIV/AIDS). These health conditions can directly impact physiologic brain functioning and, thus, increase suicide risk. The psychological effects of disability, pain, or a new diagnosis of a serious health condition can also increase the risk of suicide.

People with personality disorders are prone to suicide, especially people with borderline personality disorder or antisocial personality disorder, who likely have problems with stress intolerance and interpersonal reactivity patterns, including self-injurious behavior and aggression.

Traumatic childhood experiences, particularly the stresses of sexual or physical abuse or parental deprivation, are associated with suicide attempts and perhaps completed suicide.

The genetics of suicide risk are an important area of research and appear to influence suicide risk. While suicide risk can run in families, genes appear to account for only a portion of that risk (4). A family history of suicide, suicide attempts, or psychiatric disorders is associated with an increased risk of suicide.

There is also evidence that suggests genetic and environmental interactions contribute to suicide risk (5). Epigenetic changes (eg, DNA methylation) affecting gene expression may increase or decrease risk for suicide by affecting neurophysiology, cognition, or stress regulation. This means that negative experiences such as trauma and, conversely, positive experiences such as the social support of psychotherapy can actually change gene expression and significantly affect an individual’s resilience and risk for suicide.

Psychological traits such as a tendency toward impulsivity, cognitive rigidity, interpersonal rejection sensitivity, or severe neuroticism can also increase risk.

Choice of method for suicide is determined by many things, including cultural factors, availability of means to complete suicide, and the seriousness of intent. For example, pesticide self-poisoning occurs more commonly in rural areas in Asian and Western Pacific countries (1). Some methods (eg, jumping from heights) make survival virtually impossible, whereas others (eg, illicit drug or medication ingestion) may allow rescue. However, using a method that proves not to be fatal does not necessarily imply that the intent was less serious.

For suicide attempts, ingestion of illicit drugs, medications, or toxins is the most commonly used method. Violent methods, such as shooting and hanging, are less common among attempted suicides.

Approximately 50% of completed suicides in the United States are by firearm; males use this method more than females. Additional data regarding trends in suicide rates according to sex, race, and ethnicity have been made available by the Centers for Disease Control and Prevention (CDC) (2).

• Suicide risk assessment

• Safety planning

• Close follow-up and monitoring

The National Action Alliance for Suicide Prevention (Action Alliance) has published guidelines for recommended standards of care for patients at risk for suicide. These include recommendations for screening, suicide risk assessment, and clinical care in primary care, behavioral health, and emergency department settings (1).

It is important to note that suicide risk is dynamic. Acute risk generally lasts only a short period of time (hours to days). In the majority of suicides, patients had been seen in various health care settings during the period of acute risk, but suicide risk was not detected. Strategies to mitigate suicide-related risks that can be used by clinicians (even those outside behavioral health) include

• Using a caring, nonjudgmental response

• Providing brief interventions (eg, safety planning and lethal means counseling)

• Communicating with family and close friends of the patient

• Providing crisis and other mental health resources such as 988, the Suicide & Crisis Lifeline in the United States

• Referring the patient for appropriate care

• Following up with the patient (even by telephone) between visits

Certain periods of time are associated with an elevated risk of suicide. In particular, the period of days to weeks following discharge from the emergency department or psychiatric hospital for patients admitted for suicidal ideation or a suicide attempt is high risk and, therefore, a prime point of intervention (2).

A clinician who foresees the imminent likelihood of suicide in a patient is, in most jurisdictions, required to inform an empowered agency to intervene. Failure to do so can result in criminal and civil actions. At-risk patients should not be left alone until they are in a secure environment (often a psychiatric facility). If necessary, those patients should be transported to that secure environment by trained professionals (eg, emergency medical technicians, police officers). Advocacy efforts in the United States, the United Kingdom, New Zealand, Australia, and elsewhere aim to reform the crisis response system to move toward reliance on a more robust multi-tiered set of mental health resources, such as mobile crisis units and comprehensive crisis care, and away from reliance on emergency departments and law enforcement.

Any suicidal act, regardless of whether it is a gesture or an attempt, must be taken seriously. Every person with a serious self-injury should be evaluated and treated for the physical injury.

If an overdose of a potentially lethal drug is confirmed, immediate steps are taken to administer an antidote and provide supportive treatment (see Poisoning).

Initial assessment can be done by any clinician trained in the assessment and management of suicidal behavior. However, all patients should have a thorough suicide risk assessment—which is usually done by a psychiatrist, psychologist, or other trained mental health care professional—as soon as possible. Decisions must be made about whether patients need to be voluntarily admitted or involuntarily committed for treatment, and whether restraint is necessary (see also Behavioral Emergencies). Patients with a psychotic disorder and some with severe depression and an unresolved crisis should be admitted to a psychiatric unit. Patients with manifestations of potentially confounding medical disorders (eg, delirium, seizures, fever) may need to be admitted to a medical unit with appropriate suicide precautions.

After a suicide attempt, the patient may deny any problems because the severe depression that led to the suicidal act may be followed by a short-lived mood elevation. Nonetheless, the risk of later, completed suicide is high unless the patient receives ongoing treatment and psychosocial support.

Suicide risk assessment identifies the key drivers contributing to the individual's current suicide risk and helps the clinician plan appropriate treatment. It consists of the following:

• Establishing rapport and listening to the patient's narrative

• Understanding the suicide attempt, its background, the events preceding it, and the circumstances in which it occurred

• Inquiring about mental health symptoms and any medications or alternative treatments the patient may be taking for treatment of their mental health condition or relief of symptoms

• Fully assessing the patient’s mental state, with particular emphasis on identifying depression, anxiety, agitation, panic attacks, severe insomnia, other mental disorders, and alcohol or drug use disorders (many of these problems require specific treatment in addition to crisis intervention)

• Thoroughly understanding personal and family relationships as well as social networks, which are often pertinent to the suicide attempt and follow-up treatment

• Interviewing close family members and friends

• Inquiring about the presence of a firearm or other lethal means in the house and providing lethal means counseling (this may involve facilitating the safe storage or disposal of lethal means away from the home)

Clinicians may use validated instruments such as the Columbia Suicide Severity Rating Scale (C-SSRS) or the "Ask Suicide-Screening Questions" (ASQ) tool developed by the National Institute of Mental Health (NIMH).

Safety planning, the first step after assessment, is an essential intervention that is done to help patients identify triggers to suicidal planning and develop plans to deal with suicidal thoughts when they occur (3, 4).

Other steps clinicians should take include providing the patient with crisis resources, counseling on removal or storage of lethal means (5, 6), and referrals for appropriate risk-reduction care (eg, cognitive-behavioral therapy, dialectical behavior therapy, collaborative assessment and management of suicidality [CAMS], family therapy) (4, 7–10). Clinicians can also provide the patient with more frequent contact through outpatient visits or various forms of communication, some of which can be provided by other members of the health care team (11).

Prevention of suicide requires identifying at-risk people (see table Risk Factors and Warning Signs for Suicide) and initiating appropriate interventions.

There are strategies that health systems can employ to reduce suicide among the highest-risk patients. One such framework is called Zero Suicide, which advocates for universal training in suicide screening for all health system staff, the use of the electronic health record to help facilitate better patient care, and the use of interventions (safety planning, lethal means counseling, strong communication with the patient and family when possible, and appropriate referrals and follow-up).

Suicide-prevention efforts are critically important at the regional and national levels. These efforts are supplemented by effective health care in reducing suicide risk. Interventions at the community level have also shown promising results for reducing suicide risk (1). In addition, the development of artificial intelligence on social media platforms has helped to identify at-risk individuals and provide timely assistance (2).

There are school-based and public health interventions. One example is the Sources of Strength suicide-prevention program, which is delivered by adolescent peer leaders in high schools (3). Studies also show that appropriately training volunteers who staff suicide lifelines helps save lives (4).

Another powerful example of the effectiveness of universal and selective suicide-prevention programming is evidenced by the outcomes associated with Garrett Lee Smith (GLS) Memorial Act grants. These grants have funded youth suicide-prevention activities in the United States since 2004, on college campuses as well as in community and tribal settings in many states. Over a 15-year period, a large proportion of counties in the United States received financial funding to engage in youth suicide-prevention initiatives, including the following (5):

• Establishment of outreach, awareness-raising, and screening programs

• Provision of “gatekeeper” training (ie, educating people in key front-line roles to recognize suicide risk and intervene accordingly)

• Development of coalitions (which typically include a number of local groups, eg, local government departments of mental health or suicide prevention, nonprofit organizations focused on suicide prevention, educators, parent groups, faith-based groups, law enforcement)

• Implementation of policies and/or protocols

• Establishment and funding of hotlines

Forty percent of GLS grants are awarded in rural areas of the United States, where suicide rates are higher and where resources for programs and clinical treatment tend to be much less available than they are in other areas. In one study of counties with GLS activities compared with propensity-matched control counties that had not been exposed to GLS programs, statistically significant reductions were found both for short- and longer-term impact on suicidal behaviors and suicide deaths (6). The positive effect was greatest in rural areas of the United States.

Another innovative nationwide initiative in the United States led by the American Foundation for Suicide Prevention (Project 2025) aims to reduce the US suicide rate by 20% by 2025.

In the clinical arena, patients who are admitted to the hospital after a suicide attempt are at greatest risk of death by suicide during the first few days or weeks after discharge, and the risk remains high during the first 6 to 12 months after discharge (7). Consequently, before patients are discharged, they—along with family members and/or close friends—should be counseled about the immediate risk of dying by suicide, and an appointment for follow-up care in the first week after discharge should be made. A simple telephone call or two after discharge has been shown to significantly reduce the occurrence of repeat attempts (8). In addition, the patient and family members or friends should be told the names, doses, and dose frequency of the patient's medications.

During the first weeks after discharge, family and friends should make sure that

• The patient is not left alone.

• The patient's adherence to the prescribed medication regimen is monitored.

• The patient is asked daily about general state of mind, mood, sleep pattern, and energy (eg, for getting up, dressing, and interacting with others).

The patient's family member or friend should take the patient to follow-up appointments and should inform the clinician of the patient's progress or lack of it. These interventions should be continued for several months after discharge.

Although some attempted or completed suicides are met with surprise and shock, even by close relatives and associates, clear warnings may have been available to family members, friends, or clinicians. Warnings are often explicit, as when patients actually discuss plans or suddenly write or change a will. However, warnings can be more subtle, as when patients make comments about having nothing to live for or being better off dead. In one study, about 83% of people who died by suicide were seen by a physician in the months to year preceding their death, and approximately 24% had a mental health diagnosis in the month preceding their death (9).

Because severe and painful physical disorders, substance use disorders, and mental disorders (particularly depression) increase risk for suicide, recognizing these possible factors and initiating appropriate treatment are important contributions a physician can make to suicide prevention.

Each depressed patient should be questioned about thoughts of suicide. The fear that such inquiry may implant the idea of self-destruction is baseless. Inquiry helps the clinician obtain a clearer picture of the depth of the depression, encourages constructive discussion, and conveys the clinician’s awareness of the patient’s deep despair and hopelessness.

Even people threatening imminent suicide (eg, those who call and declare that they are going to take a lethal dose of a medication or who threaten to jump from a high height) are thought to have some desire to live. The clinician or another person to whom they appeal for help must support the desire to live.

Emergency psychiatric aid for suicidal people includes the following:

• Establishing a relationship and open communication with them

• Inquiring about current and past psychiatric care and medications currently being taken

• Helping sort out the problem that has caused the crisis

• Offering constructive help with the problem, which includes a written safety plan developed with the patient

• Beginning treatment of the underlying mental disorder

• Referring them to an appropriate place for follow-up care as soon as possible

• Discharging low-risk patients to the care of a loved one or a dedicated and understanding friend

• Providing these patients with the 988 number for Lifeline Chat & Text or with links to helpful web sites (988 Suicide and Crisis Lifeline, American Foundation for Suicide Prevention)

• Providing access to information about suicide prevention

• Brief interventions

Brief interventions are effective for reducing risk for suicide and are considered best practice. These interventions can be performed in primary care, outpatient behavioral health care, and inpatient care settings. These interventions include

• Performing a suicide risk screening

• Performing a suicide risk assessment

• Performing safety planning intervention

• Providing lethal means safety counseling

• Providing supportive follow-up phone calls, texts, or messages (which have been shown to decrease suicide risk in at-risk patients)

• Providing education to the patient and family when possible

• Providing crisis resources

Treatment that decreases suicide risk includes several types of psychotherapy:

• Cognitive-behavioral therapy for suicide prevention

• Dialectical behavior therapy

• Certain types of family therapy

• Collaborative assessment and management of suicidality

In cognitive-behavioral therapy for suicide prevention, suicidal behavior is viewed as a problematic coping behavior and as the primary problem and target of treatment, rather than as a symptom of a disorder. Treatment is focused on preventing future suicidal crises. Personal change is intended to occur by helping people modify their responses to their automatic thoughts, and by unlinking negative thought-behavior-mood patterns.

Dialectical behavior therapy focuses on increasing distress tolerance, identifying and trying to change negative thinking patterns, and promoting positive changes. It aims to help patients find more constructive ways of responding to stress (eg, resist urges to behave self-destructively).

Several types of family therapy have been developed to specifically reduce suicidal behavior and help families support their loved one. For example, the SAFETY Program is a cognitive-behavioral family intervention designed to increase safety and reduce suicidal behavior (1). Attachment-based family therapy has also shown promise as an intervention for suicidal adolescents and their parents (2).

In collaborative assessment and management of suicidality (or CAMS), a person's risk for acting on suicidal thoughts is decreased by improving their understanding of their drivers for suicidal impulses, relationship issues, and problem solving. The person who has suicidal ideation and/or behavior collaborates with a clinician to jointly develop and track a plan for staying alive and enhancing their motivation to live.

(See the American Foundation for Suicide Prevention web site for a full discussion of prevention interventions and treatment options.)

A change to the clinical approach to addressing suicide risk is the recommendation not only to focus on the patient's primary psychiatric condition(s), but also to consider suicide risk its own clinical focus (3). People with depression and other mental health conditions have a significant risk of suicide and should be carefully monitored for suicidal behaviors and ideation. Risk of suicide may be increased early in the treatment of depression, when psychomotor retardation and indecisiveness have been ameliorated but the depressed mood is only partially lifted. When antidepressants are started or when doses are increased, a few patients experience agitation, anxiety, and increasing depression, which may increase the likelihood of suicidal thoughts and even, in rare instances, suicidal behavior.

Public health warnings about the possible association between use of antidepressants and suicidal thoughts and attempts in children, adolescents, and young adults led to a significant reduction (> 30%) in antidepressant prescriptions to these populations. However, youth suicide rates increased by 14% during the same period. Thus, by discouraging pharmacologic treatment of depression, these warnings may have temporarily resulted in more, not fewer, deaths by suicide. Together, these findings suggest that the best approach is to encourage treatment, but with appropriate precautions such as

• Dispensing antidepressants in sublethal amounts

• Preferentially using antidepressants that are not lethal if taken in overdose

• Providing more frequent monitoring and visits early in treatment

• Giving a clear warning to patients and to family members and significant others to be alert for symptoms such as agitation, insomnia, or suicidal ideation

• Instructing patients, family members, and significant others to immediately call the prescribing clinician or seek care elsewhere if symptoms worsen or suicidal ideation occurs

Evidence from randomized trials has shown that , when given alone or as adjunctive therapy with antidepressants or second-generation antipsychotics (also known as atypical antipsychotics), reduces the number of deaths by suicide in patients with major depression or bipolar disorder (4

Electroconvulsive therapy (ECT) is still effective for the treatment of severe depression and for suicidal depression. ECT and transcranial magnetic stimulation (rTMS) have been approved for treatment-resistant depression and can be considered for patients with severe treatment-refractory depression, psychotic depression, or bipolar disorder. Both of these forms of treatment may also be helpful in reducing suicide risk (5, 6).

Any suicidal act has a marked emotional effect on all involved. Losing someone to suicide is a particularly painful and complex type of loss. Suicide-related grief differs from other types of loss because of unanswered questions surrounding why someone died by suicide and because many people have limited knowledge about suicide. In an effort to make sense of the inexplicable and shocking event, people frequently launch an intense search for information and generate a series of hypotheses about why the suicide occurred. This can lead to guilt, blame, and anger directed at themselves and others for not having prevented the suicide, and also anger at the loved one who died. This natural part of suicide grief is generally extremely intense in the initial few months, and often lessens in intensity in the second year and beyond.

Many individuals are affected by each suicide death, including family members, friends, colleagues and others (1). An international meta-analysis of population-based suicide loss studies found 4.3% of community members had experienced another’s suicide in the past year, and 21.8% during their lifetime. In the United States, even higher rates of exposure were found (2). From a national sample of 1432 adults, 51% had been exposed to suicide and 35% met criteria for suicide bereavement (defined as experiencing moderate to severe emotional distress related to the suicide loss) at some point in their life (3).

The physician can provide valuable assistance to patients who are suicide bereaved.

For clinicians who lose a patient to suicide, the experience can be far more distressing than other clinically related deaths. It is often similar to the traumatic and profoundly distressing experience of the death of a clinician's family member rather than to the loss of a patient. In one study, half of psychiatrists who lost a patient to suicide had scores on the Impact of an Event Scale comparable to those of a clinical population who had experienced the death of a parent (4). The loss experience for health professionals often has both personal and professional ramifications, which can include anguish, feelings of guilt, self-doubt, complicated grief, and even thoughts of leaving the profession. There are resources available to clinicians for support through several organizations (American Foundation for Suicide Prevention, American Association of Suicidology, Jed Foundation; Suicide Prevention Resource Center [5]), and curricula are also available to teach trainees and prepare them for the experiences of losing a patient to suicide (6).

Physician aid in dying (formerly, assisted suicide) refers to the assistance given by physicians to people who wish to end their life. It is controversial but legal in more than a dozen US states and is under consideration in other states. All states where physician aid in dying is legal have guidelines for participating patients and physicians, such as eligibility and reporting requirements (eg, the patient must be mentally competent and have a terminal illness with a life expectancy of < 6 months). Voluntary euthanasia and/or assisted suicide is legal in the Netherlands, Belgium, Colombia, Luxembourg, Spain, New Zealand, Australia, Switzerland, Germany, and Canada.

Physician-assisted suicide (or aid in dying) involves making lethal means available to the patient to be used at a time of the patient’s own choosing. In voluntary active euthanasia, the physician takes an active role in carrying out the patient’s request; it usually involves IV administration of a lethal substance.

Despite the limited availability of physician aid in dying, patients with painful, debilitating, and untreatable conditions may initiate a discussion about it with a physician.

Physician aid in dying may pose difficult ethical issues for physicians.

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

1. American Association of Suicidology: A developer and provider of professional training programs to mental and physical health providers who may encounter suicidal individuals, the American Association of Suicidology offers accreditation and training opportunities for organizations and individuals. This organization also provides support to clinicians whose patients have died by suicide.

   American Foundation for Suicide Prevention: Empowers those affected by suicide by funding research, educating the public about mental health issues and suicide prevention, supporting suicide survivors and those who have lost a loved one to suicide, and advocating for relevant public health policies.

2. International Association for Suicide Prevention : Publications, activities, and resources for academics, mental health professionals, crisis workers, volunteers, and suicide survivors.

3. Jed Foundation: The Jed Foundation partners with high schools and colleges to strengthen the mental health of adolescents and young adults and thus prevent suicide. This organization also provides support to clinicians whose patients have died by suicide.

4. 988 the Suicide & Crisis Lifeline: Provides 24/7 support for people in distress. Content available in various formats via text, phone, and chat for special populations (eg, for veterans, the deaf and hard of hearing, LGBTQ populations) and in Spanish.

5. Preventing Suicide: A technical package of policy, programs, and practices: Issued by the National Center for Injury Prevention and Control, this resource is a compilation of best practices to help communities and states hone their suicide-prevention activities by focusing on interventions at several levels: the level of the individual, their relationships, the community, and society as a whole.