Suicidal Ideation

Suicidal ideation affects millions of people each year, involving thoughts about death or ending one’s life that can range from fleeting wishes to detailed planning—but having these thoughts doesn’t mean you will act on them, and help is available.

Table of contents

• What is Suicidal Ideation?
• How Common is Suicidal Ideation?
• Types of Suicidal Ideation
• Causes and Risk Factors
• How is Suicidal Ideation Diagnosed?
• Treatment Options
• Getting Help and Support

What is Suicidal Ideation?

Suicidal ideation, also called suicidal thoughts, refers to thinking about, considering, or feeling preoccupied with the idea of death and suicide^[2]. These thoughts can involve wishing you were dead, wanting to go to sleep and not wake up, or thinking about, planning, or intending to end your life^[6].

It’s difficult to define exactly what suicidal ideation looks like because it’s different for each person. For example, you might fall asleep thinking about not waking up in the morning, or you might see a fast-moving vehicle and think about jumping in front of it^[2]. These thoughts can range in severity and intensity, from brief passing thoughts to persistent and distracting preoccupations.

While having a suicidal thought isn’t the same as physically attempting suicide, these thoughts can still impact your mental health and may lead to suicidal behaviors or self-harm^[2]. If you’re thinking about suicide or have suicidal thoughts, it’s important to talk to someone about it. This may help prevent the situation from getting worse.

How Common is Suicidal Ideation?

Suicidal ideation is more common than many people realize. One study reported that 10.6 million adults in the United States, or 4.3% of the adult population, experienced suicidal thoughts^[2]. Another study found that about 3.3 percent of patients in an urban primary care outpatient clinic reported suicidal ideation^[14].

Among children and adolescents in the United States, 18% have thought about attempting suicide^[2]. During 2008-09, an estimated 8.3 million adults aged 18 and over, or 3.7% of the adult U.S. population, reported having suicidal thoughts in the previous year^[6]. In 2019, 12 million U.S. adults seriously thought about suicide^[6].

These numbers show that suicidal ideation affects a broad spectrum of individuals and is a significant mental health issue^[4]. Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered an important risk factor^[6].

Types of Suicidal Ideation

There are two main forms of suicidal ideation, and they can look and feel different for each person who experiences them^[2].

Passive suicidal ideation involves suicidal thoughts without any desire to make a plan of action to harm yourself^[2]. This might include wishing you were dead or wanting to disappear, but without actively planning to die by suicide^[15]. These are sometimes called “passive” thoughts about not wanting to live or imagining being dead^[2].

Active suicidal ideation involves suicidal thoughts that motivate you to create an action plan of self-harm^[2]. This includes having a method, plan, or intent to die by suicide^[15]. When a plan is in place, you may feel at ease or withdrawn. Warning signs of suicide, like giving away valued belongings and writing a note, may occur. This usually requires emergency treatment^[2].

Causes and Risk Factors

There are many possible causes of suicidal ideation. Sometimes there isn’t a single identifiable cause, or there could be several things that contribute to suicidal thoughts^[2]. Suicidal ideation is frequently linked to mental health disorders, although it can also emerge due to situational stressors^[4].

The most common conditions associated with suicidal ideation include major depression and alcohol abuse. More than 90 percent of completed suicides in all age groups are associated with psychiatric disorders, including substance abuse^[14]. The risk for suicide in patients with mood disorders is 15 percent, and the risk is highest in the early stages of the illness^[14].

Other mental health conditions that can increase risk include substance use problems, bipolar disorder, schizophrenia, panic disorder, borderline personality disorder, and anxiety disorders^[5]. However, those who go on to experience severe suicidal thoughts rarely have “pure” depression, but usually depression that occurs alongside alcohol abuse^[14].

Beyond mental health conditions, several life circumstances can increase risk. These include experiencing violence, child abuse, bullying, or sexual violence^[3]. Stressful life events such as the death of a loved one, separation, divorce, or recent unemployment can also contribute^[14]. Having access to firearms, living alone, being widowed or divorced, and the presence of stressful life events are additional risk factors^[14].

Some evidence suggests an increased risk of suicidal ideation in patients with certain medical conditions including cancer, head injury, and peptic ulcer disease^[14]. A previous suicide attempt is considered one of the best predictors of suicidal thoughts and behaviors^[14], and a family history of suicide attempts is also a risk factor^[14].

Certain symptoms are particularly associated with suicidal ideation, including hopelessness, loss of pleasure in activities (anhedonia), insomnia, severe anxiety, impaired concentration, restlessness and agitation (psychomotor agitation), and panic attacks^[14].

How is Suicidal Ideation Diagnosed?

A healthcare provider or mental health professional will diagnose suicidal ideation after asking you a series of questions to learn more about your thoughts of suicide^[2]. While there are several types of assessments and questionnaires, there isn’t a specific test to predict whether you’re going to harm yourself. The goal is to help your provider learn more about what’s going on, including the cause of the suicidal ideation, so they can help you treat it^[2].

There are several types of suicidal ideation scales available to help healthcare providers learn more about how suicidal ideation affects you and its severity^[2]. Your provider will typically ask you several “yes” or “no” questions. For example, questions on the Columbia-Suicide Severity Rating Scale might include^[2]:

• Have you wished you were dead or wanted to go to sleep and not wake up?
• Have you had any thoughts about killing yourself?
• Do you have a plan in place to kill yourself?
• Have you harmed yourself or done anything to fulfill the plan you created (like purchasing a weapon, giving away valuables, writing a note)?

If a provider asks you questions like these, it’s important that you answer honestly. They’re looking out for your health and safety, and your truthfulness can open doors to treatment^[2].

Your doctor may also do a physical exam, tests, and in-depth questioning about your mental and physical health to help determine what may be causing your suicidal thinking and to determine the best treatment^[10]. Assessments may include evaluating for mental health conditions, physical health conditions, and alcohol and drug use^[10].

Treatment Options

There are several treatments with evidence demonstrating that they can reduce suicidal ideation and behavior, as well as support the development of a more fulfilling life^[13]. Treatment approaches can include therapy, medication, hospitalization when needed, and various supportive strategies.

Therapy Approaches

Research strongly supports addressing and treating suicidal thoughts and behaviors specifically and directly, independent of any additional diagnosis or challenge^[12]. Several evidence-based therapies have been found to reduce suicidal ideation and behavior^[15]:

Cognitive-behavioral therapy for suicide prevention (CBT-SP) is a treatment that focuses on broad life, psychological, and behavioral changes, including managing suicidal thoughts and reducing behavior as a component. It helps with difficulties people may have with anxious or negative thoughts, moods, and social, occupational, and health experiences^[13].

Dialectical behavior therapy (DBT) is another treatment approach that has been shown to reduce suicidal ideation and behavior^[13][15].

Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that helps an individual determine the problems that make them consider suicide, called suicidal drivers. Using specific assessment forms, the individual works collaboratively with an empathic, supportive mental health clinician to have honest conversations that directly address suicidal thoughts and impulses, with the goal of developing a plan to manage suicidal drivers^[13].

Attachment-Based Family Therapy (ABFT) is particularly helpful for younger individuals and involves family members in the treatment process^[13][15].

Medication

For patients with chronic suicidality, clozapine remains the only U.S. Food and Drug Administration approved medication specifically for reducing suicide risk, and its use is predominantly for patients with schizophrenia and related disorders^[15]. An abundance of literature supports the use of lithium among patients with mood disorders, including those with major depressive disorder^[15].

Antidepressants are widely used and remain helpful in reducing suicidal thoughts and behaviors, primarily among patients with mood disorders^[15]. For an acute suicidal crisis, ketamine, and perhaps esketamine, are emerging as important tools^[15].

Other Approaches

Brief interventions that provide tools for managing suicidal crises and for reducing suicidal behaviors include safety planning interventions, lethal means counseling, and crisis response planning^[15]. Creating a safety plan is a personalized guide designed to help you through a crisis. It should include recognizing your personal warning signs, using your own coping strategies, and knowing who to contact for support^[8].

Treatment guidelines focus on the importance of optimizing treatment of the psychiatric conditions known to be associated with suicide risk^[15]. When needed, hospitalization may be recommended to provide intensive monitoring and support, especially when active suicidal ideation with a plan is present^[2].

Getting Help and Support

If you’re thinking about suicide or have suicidal thoughts, it’s important to talk to someone about it^[2]. You can call or text the Suicide & Crisis Lifeline by dialing 988. However, you don’t need to be in a “crisis” to call the Lifeline. Someone is available to talk to you 24/7^[2].

Being connected to family and community support and having easy access to healthcare can decrease suicidal thoughts and behaviors^[3]. You don’t have to deal with challenges on your own. Those you choose to confide in can provide encouragement and help you through difficult times^[8].

Speaking to someone, whether by going to a therapist or by attending a support group, can help you feel better and improve your mental health^[8]. Many patients who experience suicidal ideation have seen their primary care physician within several months, making these healthcare providers an important point of contact for getting help^[14].

Building a support network is crucial. Relationships with friends, family, and significant others built on trust and companionship are a protective factor against suicidal thoughts and behaviors. It’s important to find the people in your life that you can always confide in, feel comfortable around, and can contact at any time^[8].

You may feel less isolated when you’re connected more to others. Consider joining an interest group, volunteering, taking a class, or starting a new hobby^[8]. Whether your community is at work, school, church, or a club or a team, having a group of people who encourage help-seeking and support is one of the most important aspects of suicide prevention^[8].

Remember that healing, hope, and help can happen^[8]. Most people who actively manage their mental health conditions go on to engage fully in life^[5].