How to Spot the Potential Warning Signs of Suicide

Suicide expert Dr. Mark Russ on recognizing suicidal behavior, and how to help someone who is suffering and may be contemplating taking their own life.

Illustration of woman demonstrating potential warning signs of suicide
Illustration of woman demonstrating potential warning signs of suicide

Despite growing public attention and efforts to curb the country’s suicide rate, the statistics are sobering: Suicide is the 10th-leading cause of death in the United States, according to the American Foundation for Suicide Prevention. In 2017, more than 47,000 Americans died by suicide, a 33% increase since 1999.

“Suicide is both a public health problem and, of course, an extremely individual one,” says Dr. Mark Russ, vice chair for clinical programs and medical director at NewYork-Presbyterian Westchester Division. “It’s critically important to continue to raise public awareness of suicide and suicide risk to try to get our arms around this, to do more research to understand the underpinnings of suicidal behavior, and educate people as best we can, including how to intervene on the level of families, schools, employers, and the medical community.”

Stressful life events are unavoidable, but it’s important to remember that painful feelings will not last forever, Dr. Russ emphasizes.

“I think many people feel that what they are feeling in the moment they will always be feeling, and therefore ‘I need to end this in some way,’” he says. “That is not true. We know that moments of emotionally intensely painful feeling tend to come and go. They don’t last forever; that is just sort of the way the brain works. Sometimes, just letting people know that what they are feeling now is not something they’re going to need to bear forever can help — that even if they do nothing, in time, they are likely to feel better.”

How do you know if someone you love is considering taking their life? And is there a way to help? Health Matters spoke with Dr. Russ to better understand what may drive someone to take their life, and potential warning signs of suicide.

Why do you think the suicide rate is rising?
Dr. Russ: It’s unclear why the rate is increasing. It could have to do with more people reporting it, or societal stressors. Some have speculated that it could be related to the opioid crisis, social media, availability of information, bullying, or copycatting. Financial concerns are also a huge stressor for many people.

Who is most at risk?
The rates are rising in middle-aged individuals, particularly among white men, as well as adolescents and young adults. There are also increases among the elderly and the African American community.

We can only speculate, but for a middle-aged man it could have something to do with financial stressors, phase of life, the prospect of losing one’s job, or actually losing one’s job, retirement without adequate resources, or interpersonal issues involving family or divorce. For young people, possible factors include social media stress in terms of bullying, and tremendous social stress around getting into and succeeding in college and beyond.

Suicide is highest in people with existing mental and psychiatric disorders. We believe that there is a genetic component to suicide risk, and we know from studies that suicide can run in families.

What could trigger suicide?
Any kind of a loss is potentially a trigger for thinking about ending one’s life. It’s important to note that there is no absolute scale for loss. You can’t judge the meaning or impact of a loss to an individual. A circumstance or event that one person might regard as relatively trivial may be extremely impactful to an individual based on their experience, their interpersonal dynamics and who they are in the world. Some people may be very sensitive to humiliation or to being slighted. One person may think that’s just a part of life, but for another person it may be devastating.

“Struggling with depression, anxiety, or having thoughts of suicide is not uncommon, yet many people seem to distance themselves from it — perhaps because it’s not the way that people want to see themselves.”

— Dr. Mark Russ

What are the warning signs that someone may be considering suicide?

  • A change in someone’s mood or behavior, particularly along depressive and anxious lines, or isolating themselves. This can come across as either a sad mood, a feeling of disconnection, or social withdrawal. People at risk for suicide may isolate themselves. They may be quieter or not enjoy things the way they used to. Adolescents who used to love to engage in sports or play video games may stop doing that. If you get the sense that they are lacking pleasure in life, that is an extremely important warning sign.
  • Any statements that express a sense of hopelessness, helplessness, or worthlessness are evidence the individual may be becoming depressed. People may make a direct or indirect comment about suicide. Often, they may use euphemisms, like “I can’t take this anymore,” “I’m at the end of my rope,” “I want to throw in the towel,” or “Not sure how much longer I can go on.”
  • Changes in intake of alcohol or use of illicit drugs.
  • Signs of intense agitation, anxiety, or feelings of tremendous inner pain. This is an extraordinarily important warning sign of suicide because it may suggest that they are going to act soon.

What do you do if you see these warning signs of suicide?
Awareness is most important. People may deny that they or a loved one could be considering suicide because it’s too painful a thought. The natural tendency is to minimize symptoms and risks when they see them in other people. A loved one, for example, who has just suffered a traumatic life event, or experienced a situation that is painful, problematic, or difficult, might be overwhelmed by it and might be thinking that this is not something they can take anymore. The first step is to consider the possibility that suicide is among the potential outcomes of the situation and to listen very carefully.

How can you be a good listener?
Being a good listener can be tough, and it’s what we in behavioral health spend many years of training to do, because the natural inclination for most people is to jump in and share their experiences, give advice, and make judgments, all of which may not really be helpful in trying to help somebody who may be going through a very, very tough time.

  • Keep your ears open and resist the temptation to talk a lot. Be present for the person and don’t interject with “quick” or “easy” solutions. Understand that if there were a quick and easy solution, this person would likely have already thought of it.
  • Convey a sense of caring and interest. This can be done nonverbally and verbally, but try to provide a validation and acknowledgment of their current situation without making a judgment about it. Show that you see they are extremely depressed or despondent, and ask if they can tell you more about it.
  • Ask questions that are open-ended and allow the person to talk as much as possible. Allow periods of silence. It conveys a respect for the person and an interest, that you’re willing to forgo your own needs in the moment for the sake of helping them. It’s not easy to do, but important.
  • Create the time and space for someone to open up. You want to create a space that is private and give them enough time to talk.

What else can someone do to help if they suspect someone is considering taking their life or see a potential warning sign of suicide?
It’s OK to come out and ask “Are you feeling suicidal?” It’s not going to put the idea in their head if it wasn’t there before. Some may say they don’t have suicidal thoughts because it may be too painful to admit or it may be embarrassing because of the stigma associated with mental illnesses and suicide. Sometimes, it’s better to ease into the question by using terms that are less charged, like “Are you feeling overwhelmed?,” “Are you feeling that you can’t go on?,” or “Are you feeling at the end of your rope?” The idea is to normalize the experience and show that it’s understandable for someone who has gone through something difficult to have these thoughts.

Dr. Mark Russ, expert in identifying the warning signs of suicide.

Dr. Mark Russ

What else is important to know?
Getting someone professional help is critical. You don’t want to be in a situation where you are the lifeline for another human being. That is fraught with danger for that person and for you. Even if the person doesn’t kill themselves, they put you in an untenable situation that you’re not prepared for and will likely cause a great deal of anxiety for you. The best thing you can do is whatever you can to get that person into treatment. It may range from providing a suicide hotline number to actually calling the police and an ambulance to bring them to the emergency room, depending on the acuity of the circumstance.

What if someone has ongoing feelings of suicide?
Often, suicidal feelings can last a long time and be chronic. In addition to treatment, it’s important to create a safety plan. There should be a very clear, and preferably written, point-by-point plan of what a person will do if they feel suicidal. This is hopefully done in the context of treatment, but it’s important for the family to be aware of it whenever possible. The plan can include anything from providing a suicide hotline number to engaging in coping mechanisms they’ve learned as part of therapy, going to an ER, or calling a therapist, friend, or parent. Coping skills may include distracting behaviors, like walking around the block, taking a bath, or watching a funny movie — whatever seems to work for that individual. But a list of activities and steps that they are going to take before they act or harm themselves is useful and important.

Even if they are not suicidal in the moment, these feelings tend to recur. We should have the expectation that they’re going to feel this way again and help them anticipate the circumstances under which these thoughts or feelings are likely to emerge. A young adult with a history of becoming suicidal after they fail a test may not feel suicidal now, but might if they fail another test. Knowing the steps to take to help in the moment to get over the crisis is extremely important.

Is suicide an impulsive act?
Not always. Some people think about suicide for a very long time and plan carefully and basically make a decision that they feel is rational, although others would not agree, that their life is just not worth living. Others may be extremely impulsive, and the suicidal act may come at a moment of heightened emotion, in particular heightened anxiety and this sense of what we call psychic angst — pain in your being that just feels unbearable in the moment and may push someone to do something impulsively. Then, of course, there’s everything in between.

Can you predict who will take their life?
We cannot predict who is going to die by suicide. Most people who experience or exhibit warning signs of suicide don’t take their lives. There are many risk factors, but there is a lack of specificity in those risk factors. Many people get depressed or go through periods of hopelessness. For statistical reasons having to do with the relative infrequency of suicide and lack of specificity of any risk factor or group of risk factors related to suicidal behavior, it makes it impossible to predict who will die by suicide.

There is no blood test. There is no brain scan. There is no psychological test that can tell us if and when an individual will engage in suicidal behavior. We look for triggers and warning signs that have been associated with suicide risk in vulnerable individuals because it makes common sense to do so and can save lives. But in the end, we don’t know what is in the mind of that person who ultimately decides to take their own life. We don’t know that final thought because it’s never available to us. Because of that, there’s a certain degree of humility that I think all of us who work with people who struggle with suicidal feelings have to accept and understand.

Is there still a stigma around mental illness and suicide?
I think it’s getting better very slowly, but it is still a huge problem. Efforts of organizations like the National Alliance on Mental Illness are making an impact, and public figures coming out and sharing their mental health struggles helps too. But I think that the stigma remains a problem, particularly in some communities more than others. When there are cultural prohibitions or consequences to having a mental illness or getting treated for one, it makes it that much more difficult to access care.

Struggling with depression, anxiety, or having thoughts of suicide is not uncommon, yet many people seem to distance themselves from it — perhaps because it’s not the way that people want to see themselves. The sense of emotional well-being is so closely connected to who you are in the world. It’s different than if you have pneumonia or diabetes, if something happens to you — somehow the idea of mental illness isn’t viewed the same way, perhaps because it’s so closely aligned with a sense of self and identity — even though these are brain diseases.

How can people who have lost someone to suicide cope?
Be aware of your feelings and understand and accept the fact that you are going to have very strong feelings about what happened. That’s normal and appropriate, and you will need support. The extent of that support may be limited or may be extensive in terms of getting into therapy.

There is no constructive role for guilt or self-blame — there has already been one casualty, and we need not create any more. Feelings of guilt, loss, anger, and, of course, tremendous sadness are all natural feelings that can be dealt with and understood in the context of the circumstance.

If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741.

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