Suicidal Behavior

Worldwide over 720,000 people die yearly from suicide, which is the third leading cause of death in people from 15 to 29 years old (1).

Statistics on suicidal behavior are based mainly on death certificates and inquest reports. Although surveillance of suicide mortality in the United States is improving, reported rates are still thought to be an underestimate of the true incidence of suicide. 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 case of suicide from various sources to provide a clearer understanding of the causes of suicide. The NVDRS is now in place in all 50 states, the District of Columbia, and Puerto Rico.

In the United States, from 2000 to 2018, suicide rates increased steadily, with a total increase of 37% (from 10.4 to 14.2/100,000 people per year) (2). From 2018 through 2020, rates decreased by 5%. Rates then increased again, returning in 2022 to the same level as in 2018, and then remaining fairly stable in 2023 (14.2/100,000).

United States suicide rates vary by age, gender, and race/ethnicity. From 2021 to 2023, suicide was the 11th leading cause of death for people of all ages (3). In 2023, it was the second leading cause of death for people ages 10 to 34 years. Age groups with the highest rates of suicide were ages 75 to 84 (19.4/100,000) and ≥ 85 years (22.7/100,000). The racial/ethnic group with the highest suicide rate was non-Hispanic American Indian and Alaska Native people (23.2/1000,000).

In terms of the spectrum of suicide-related experiences, in 2023 an estimated 12.8 million people in the United States seriously thought about suicide, 3.7 million made a suicide plan, 1.5 million attempted suicide, and 49,000 died by suicide (2). Suicidal ideation is a fairly common experience in the general population and more common in clinical  patient populations (4). 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 (5). From a lifespan perspective, adolescents and young adults have the highest incidence of suicidal ideation; females attempt suicide more than males, but males die by suicide at more than twice the rate of females.

Because suicide is known to be a multifactorial, complex health outcome, it is challenging to identify the reasons for changes in population rates, 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 (6).

A suicide note is left by approximately 1 in 6 people who complete suicide (7). The content may allude to or specify 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, sense of isolation). The intersection of these and other life stressors or losses may precipitate suicide.

Male deaths by suicide outnumber female deaths approximately 2.5:1 to 4:1 globally (8) and nearly 4:1 in the United States (2). 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, groups that include a higher proportion of males to females.

Youth suicide rates in the United States had seen decreases in the 1990s, after more than a decade of previous increases. Rates began to increase again in the early 2000s. The cause of increasing trends in suicide rates among children and adolescents is likely multifactorial, including the following (9):

• Inadequately diagnosed and treated psychiatric conditions (including major depressive disorder, bipolar disorder, substance use disorders, psychosis, eating disorders, attention-deficit/hyperactivity disorder [ADHD], anxiety disorders, and/or trauma)

• Significant increases in firearm ownership by household (ie, wider accessibility of lethal means) during the early 2000s and more recently during the COVID and post-COVID years (10)

• General medical 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)

The role of social media in suicidality is complex. There appear to be types of social media exposure, in particular those involving bullying and victimization, that increase the risk of both suicidal ideation and attempt, while other types, primarily involving social connection, appear to be protective (11, 12, 13, 14) Evidence is mixed on the effect of the magnitude of social media or internet exposure ("screen time") with some studies suggesting an increased risk of suicidal behavior with increased exposure, mediated at least in part by sleep deprivation, and some studies suggesting no effect.

The U.S. Surgeon General called on Congress in 2024 to place a warning label on social media due to its detrimental effects on the mental health of youth and young adults (15). However, the benefit of regulatory interventions is unclear. For example, some data suggest that boxed warnings issued by regulatory agencies about the increased risk of suicidality in children and adolescents associated with antidepressant use may have resulted in decreased treatment of major depressive disorder (16, 17).

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 because these methods have higher fatality rates.

In the United States in 2023, firearms were the most common method used in completed suicides, accounting for more than half (55.33%) (2). Males use this method more than females (3, 4). The next most common methods were suffocation (24.37%) and poisoning (12.09%).

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 between 1 to 5% (with some estimates up to approximately 10%) of all adolescent suicides (5, 6).

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 portrayals of suicide in popular media. Conversely, media coverage with positive messaging about a suicide prevention 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, suicide prevention messaging 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 of a group 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.

Other categories of suicide are rare. These include

• Group suicides

• Murder/suicides

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

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 (1, 2, 3). 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 had a diagnosable psychiatric disorder at the time of their death (4). (See table Increased Risk of Suicide in Psychiatric Disorders.)

One of the most common, potent, and remediable risk factors for suicide is depression (1). 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 occur concurrently with or as symptoms of major depression or bipolar depression.

People with schizophrenia die by suicide at a much higher rate than the general population, with as many as 14% of patients with schizophrenia dying by suicide (5). Factors associated with increased risk of suicide 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. Over one third of people who die by suicide have consumed alcohol before the attempt, and about half of them were intoxicated at the time (6). Younger people, who are generally more prone to impulsive behavior (including binge drinking) are particularly susceptible to alcohol's effects; moderate levels of intoxication can result in their using more lethal suicide methods (7). However, people with an alcohol use disorder are at increased risk of suicide even when they are sober. In fact, people who misuse alcohol, particularly those who engage in binge drinking, often have deep feelings of remorse during dry periods, and this feeling of remorse may be associated with a higher risk of suicide.

New-onset or recent diagnosis of general medical conditions are also associated with increased suicide risk (eg, diabetes, seizure disorder, chronic pain, multiple sclerosis, cancer, HIV infection). The psychological effects of disability, pain, or a new diagnosis of a serious health condition can also increase the risk of suicide. Some general medical disorders directly impact physiologic brain functioning and, thus, may increase suicide risk. Serious medical conditions, especially those that are chronic and painful, contribute significantly to suicides in older adults, with over 30% of suicides in one study occurring in patients with physical health problems (8, 9).

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

Traumatic childhood experiences, particularly trauma due to sexual or physical abuse or parental neglect, are associated with suicide attempts (10, 11, 12).

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 (13). 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 (14). 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 are also associated with increased risk of suicide.

Risk factors for suicide are listed in the table Risk Factors and Warning Signs for Suicide.

Prevention of suicide requires identifying at-risk people (see table Risk Factors and Warning Signs for Suicide) and initiating appropriate interventions (1).

Suicide-prevention efforts are critically important at 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 (2). In addition, monitoring of social media platforms using artificial intelligence has helped to identify at-risk individuals and provide timely assistance (3).

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 (4). Studies also show that appropriately training volunteers who staff suicide lifelines helps save lives (5).

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. A study of the program over a 15-year period reported that a large proportion of counties in the United States received financial funding to engage in youth suicide-prevention initiatives, including the following (6):

• 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 (7). The positive effect was greatest in rural areas of the United States.

There are strategies that health systems can employ to reduce suicide among the highest-risk patients (8). One such framework for children and youth is called Zero Suicide, which advocates for universal training in suicide screening for all health care 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).

In the clinical settings, 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 (9). 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 (10). 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 hospital 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).

A 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, approximately 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 (11).

Clinicians should be aware of risks factors for suicide as part of routine inpatient and outpatient care. 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.

All patients with depression 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 the patient to an appropriate place for follow-up care as soon as possible

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

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

• Providing access to information about suicide prevention

• Brief interventions

• Suicide risk assessment

• Safety planning

• Close follow-up and monitoring

• Psychotherapy

• Medications

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, in the United States, 988, the Suicide & Crisis Lifeline

• 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 U.S. 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 or emergency department). If necessary, those patients should be transported to that secure environment by trained professionals (eg, emergency medical technicians, police officers).

Short of imminent likelihood of suicide, which is a clinical determination, law in the United States does not allow for communicating with family members without the patient's permission. However, clinicians are encouraged to maximize support from family members by asking the patient if the patient would like to include a trusted family member or friend in mental health support.

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 and assessed for suicide risk.

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

Initial assessment can be performed 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 performed 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.

Brief interventions are effective for reducing risk for suicide and are considered best practice (3). 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 risk of suicide in at-risk patients)

• Providing education to the patient and family when possible

• Providing crisis resources

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 psychiatric disorder 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 performed to help patients identify triggers to suicidal planning and develop plans to deal with suicidal thoughts when they occur (4, 5).

Other steps clinicians should take include providing the patient with crisis resources, counseling on removal or storage of lethal means (6, 7), and referrals for appropriate risk-reduction care (eg, cognitive-behavioral therapy, dialectical behavior therapy, collaborative assessment and management of suicidality [CAMS], family therapy) (5, 8–11). 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 (12, 13).

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 the question of why that person chose to die by suicide often remains unanswered, and 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.

See More Information for educational and support resources that can be provided to patients who have experienced a suicide loss, as well as for patients with family members with suicidal thoughts or behaviors.

Many individuals—including family members, friends, colleagues, and others—are affected by each suicide death. 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 (1). 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 (2). Clinicians 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 (3). 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 [4]), and curricula are also available to teach trainees and prepare them for the experiences of losing a patient to suicide (5).

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

2. American Foundation for Suicide Prevention; I've Lost Someone

3. Dougy Center

4. International Association for Suicide Prevention

5. Jed Foundation

6. Now Matters Now

7. Speaking of Suicide

8. 988 the Suicide & Crisis Lifeline