Suicide Risk Factors and Warning Signs: What we’ve learned from the research

It’s important to understand that there are many potential suicide risk variables, the following are a subset of variables with strong empirical research support. 

SUICIDE RISK FACTORS

Suicide risk factors are diverse and multifaceted, encompassing a range of individual, social, and environmental factors. They include personal characteristics such as mental health conditions, previous suicide attempts, substance abuse, and other factors. Understanding and addressing these factors can aid in suicide prevention efforts.

The history of previous suicide attempts has long been considered a major risk factor related to future suicidal behavior. The risk of such future behavior increases significantly with any past attempt behaviors, particularly a multiple-attempt history of two or more bona fide attempts. 

When a person has suicidal thoughts, the details and frequency of these thoughts are critical. It’s important to determine whether such thoughts are a brief passing fantasy or something they have explored, made a plan and taken specific actions. By directly asking a person whether they are thinking about taking their life, with appropriate follow-up questions, you will be better able to assess their risk of suicide. Contrary to some popular beliefs, several research studies have clearly shown that asking a person suicide-related questions WILL NOT put the idea of suicide in their head.

Do not be afraid to ask, something like:  “It sounds like you are having a difficult time, have you ever wished you were dead?” or “ It sounds like you are really struggling, have you ever wished you could just go to sleep and not wake up?”.  

• If the answer is “no”, ask: “In the past three months, have you thought about taking your life, or prepared to do anything that could end your life?”
• If the answer is “yes” ask: “Have you thought about how you might do this?”

Asking your friend or family member to describe their suicide-related thoughts and provide specifics on the frequency and duration of these thoughts will not only help you better understand your loved-one’s struggles and suicide risk factors, but also send them a clear message that you truly hear them and want to listen. You are telling them that they are not alone and you are willing to try and understand their pain.  

Suicide Plan

 While suicidal thoughts are an important suicide risk factor, research has indicated that the specific details and seriousness of planning and preparing for suicide can be predictive of the likelihood of future death by suicide. In other words, someone with a vague, inexact, or nonspecific plan is generally much less serious about taking their life, as opposed to someone with a plan that includes a particular method, place, time, and date for how they will end their life.   

The next important question to ask a friend or family member who has shared their suicide plan with you is whether they have access to the item or method they plan to use for carrying out the plan, such as a stash of sleeping pills or access to a firearm. These items are referred to as “lethal means”, and limiting their access can be an important step in suicide prevention. You might ask: “Have you started to work out the details of how you plan to kill yourself?” or “Do you have an idea of where and when you will do it?”

If your friend or family member does have access to the lethal means that they describe in their suicide plan, your next critical step is to work with them to develop a “safety strategy” to remove their direct access to the lethal item, at least until their suicidal crisis is over. For example, are they willing to let you hold their pills for safe keeping?  Are they willing to let an appropriate and trusted friend or relative keep their gun until their suicide crisis is over? Are they willing to take a different route to work or school so that they do not walk by railroad tracks?  Are they willing to avoid parking their car in a tall parking structure?  

In general, preparation behaviors are often related to organizing the suicide attempt action itself, such as obtaining the lethal means, as well as doing research to determine a lethal dose of drugs or determining a suitable location where the possibility of interruption or intervention may be reduced. Other preparation behaviors may include putting one’s affairs in order, such as writing a will, writing suicide notes, shooting a good-bye video, posting a cryptic Facebook message, doing a favorite activity one final time, saying a final good-bye to friends and family, or giving away prized possessions. All of these behaviors may indicate significantly increased suicidal risk for the individual. In these circumstances, you might ask: “Have you collected pills?” or “Have you obtained a gun?” or “Have you given away valuables, written a will or a suicide note?

Suicide Rehearsal

“Rehearsal behaviors” is a suicide risk factor that typically involves the acting out of the planned suicide attempt. For example, someone may obtain a rope, find a beam in the garage, secure the rope at a certain length, position a short stool, and even step up on the stool and place the rope around their neck without actually stepping off the stool to make the attempt. Such rehearsal behavior is serious.  You might ask: “Have you held the gun, but changed your mind?” or “Have you cut yourself?” or “Have you hung a rope?”

WARNING SIGNS of Suicidal Ideation

In contrast to risk factors “warning signs” for suicide typically center on being extremely upset and agitated —when someone feels totally out of control . Warning signs for suicide suggest an immediate risk of self-destructive behavior. For example, in the case of heart disease (which is the #1 cause of death around the world), many people have both short and long term risk factors (e.g., obesity, hypertension, high cholesterol, and smoking) but do not die of heart disease. In contrast, someone with such risk factors might have key warning signs that prompt urgent intervention to avert a heart attack (e.g., chest pains, pain in their left arm, feeling faint). 

Below are various topics when experienced in a very serious manner can contribute to imminent for self-harm behaviors, such as cutting or burning one’s skin, over-dosing and suicide attempts.

Severe Substance Abuse

. The  extremely excessive use of alcohol or drugs during a crisis can directly contribute to being highly upset and out of control  which may trigger individuals to harm themselves or even make a suicide attempt.

Impulsivity in Decision Making

Generally, impulsivity refers to the lack of ability to think through the consequences of one’s actions, in other words “acting without thinking”. Suicide attempts and deaths often occur when someone is upset, distressed, anxious, highly emotional and/or highly impulsive. The risk is further increased if impulsive behaviors are essentially self-destructive, for example, a history of fighting, pathological gambling, kleptomania, or other similar impulsive disorders.  

Extreme Reaction to a Death or Significant Loss

For many years, suicidologists have known that suicides often occur after someone has experienced a loss, which may seem to trigger the suicidal act. Such losses may be big or small; it can be one particularly significant loss or an accumulation of several lesser losses. Examples may include a divorce, a romantic breakup, a financial disaster, loss of a job, the death of a loved one or a pet— any event that has significant meaning to the person. Additionally, suicide-triggering losses can be symbolic—for example, retirement from a meaningful career. Although losses often contribute to the circumstances leading up to a suicide, usually such losses are not the only reason for suicidal behavior. 

Research studies have shown that relationship issues are often the number one suicide-related concern of people struggling with suicidal thoughts. These problems could be romantic issues or relationships with friends, parents or siblings. In contrast, we also know that social relationships can protect a person against suicide. It is important to not let the highly suicidal person be or feel alone. The perception of being a burden to others can be a particularly important relationship problem when experienced by someone who is extremely upset. Experiencing oneself as a burden on others can create a dangerous downward spiral, wherein the individual experiencing suicidal ideation is disinclined to seek help. In the mind of the person with suicidal thoughts, their suicide can be perceived as a “gift” to the people in their lives who they believe are “weighed down” with the troubles of the person who struggles with suicide. 

There are studies that suggest that general health-related issues, particularly if these issues are constantly occurring or chronic, may be related to suicidal thoughts and behaviors – particularly if these issues are chronically occurring or terminal in nature. While many people live out their lives in chronic physical pain, other can find such pain to be utterly unbearable, which may lead to increased suicidal thoughts as a way to finally escape the pain. 

Sleep problems related to insomnia, hypersomnia, and nightmares have been shown to be significant suicide risk factors in adolescents and adults and the lack of sleep impacts REM sleep which is critical to everyone to maintain, and the heightened stress levels caused by lack of proper sleep can exacerbate a sense of peace and calm.   

Legal problems can contribute significantly to suicidal risk.  There is often a window of considerable suicidal risk shortly after a person is first faced with a legal accusation. Similarly, financial issues from poverty, unemployment, credit card debt, payday lenders, owing back taxes, and simply not being able to make ends meet can all contribute to increased suicidal risk.