For healthcare providers, identifying warning signs and risk factors, accessing services, and providing evidence-based care are key challenges. In the United States, about 33% of people who took their life were in contact with mental health services the year before their death. Nearly half of those were seen in primary care the month before death (McCabe et al., 2017). Because of these sobering statistics it is critically important that healthcare providers be educated about and aware of risk factors and warning signs associated with suicidal behaviors.

Warning Signs

Warning signs are actions or behaviors that are observed by or reported to another, and indicate risk for suicide within minutes, hours, or days. Warning signs can be acute and urgent or simply red flags for concern.

About 80% of people who attempt suicide show some sort of warning sign. Knowing and recognizing these signs can help family and friends take action before suicidal thinking turns into action. Recognition of warning signs provides an opportunity for early assessment and intervention.

Widely accepted general suicide warning signs include:

• Anxiety, agitation, sleeplessness
• Feeling that there is no reason to live
• Rage, anger, or aggression
• Recklessness
• Increased alcohol or drug abuse
• Withdrawal from family and friends
• Abrupt mood swings
• Hopelessness, feeling trapped (USDVA, 2019)

Three specific suicide warning signs require immediate attention:

1. Communicating suicidal thought verbally or in writing, especially if this is unusual or related to a personal crisis or loss
2. Seeking access to lethal means such as firearms or medications
3. Demonstrating preparatory behaviors such as putting affairs in order (USDVA, 2019)

Risk Factors

A risk factor is anything that makes it more likely for a person to develop a disorder. Although suicide is rare in comparison to its associated risk factors, increased risk has been associated with prior attempts, emotional and financial loss, illness, hopelessness and isolation, childhood experiences, and access to lethal means. Increased risk is also associated with relationship, community, and societal issues such as local epidemics of suicide, stigma, lack of medical services, family history of suicide, and certain cultural and religious beliefs.

Mental Illness

Although suicidal behavior is strongly associated with mental disorders, no linear relationship exists; the vast majority of people with mental disorders do not experience suicidal behavior. Because of this, psychiatric disorders as risk factors for suicidal behavior have only limited predictive power (Brüdern et al., 2018).

Suicide is nevertheless overrepresented in people with mental illness, and a large percentage of suicide victims have a diagnosable mental health disorder. The odds for suicide in people with severe depression, schizophrenia, and bipolar disorder are approximately 3 to 10 times that of the general population, with a higher risk in males than females. Despite this, suicide occurs in only 3% to 5% of these cases (Fosse et al., 2017).

A poor social network and social withdrawal, command hallucinations,* delusions, and mental disorders other than depression are associated with an increased risk of suicidal behaviors in people with mental illness. This can include bipolar disorder, schizophrenia, coexisting physical illness, family history of mental illness, multiple admissions to inpatient treatment, unplanned discharge, and prescription of antidepressants (Fosse et al., 2017).

*Command hallucinations are hallucinations in the form of commands; they can be auditory or inside of the person's mind or consciousness. The contents of the hallucinations can range from the innocuous to commands to cause harm to the self or others.

For patients admitted to a specialized mental health facility, there is a 50- to 200-times increased risk of suicide compared to the population at large. In two meta-analyses that included 42 studies and close to 3,500 suicide completers, central suicide risk factors were:

• Prior suicide attempts
• History of deliberate self-harm
• Family history of suicide
• History of suicidal ideation
• Depression, hopelessness
• Agitation
• Social or relationship problems (Fosse et al., 2017)

Although both evidence and common sense suggests that suicides can be avoided with effective treatment of mental disorders, most people in need do not receive adequate treatment. This is because mental conditions are under-recognized, which limits the potential to identify and appropriately treat individuals at risk for suicide.

Medical Issues, Stress, and Illness

Certain medical conditions, chronic illness, and stressful life events are associated with an increased risk for suicidal behaviors. Chronic pain, ongoing stress, cognitive changes, loss of mobility, sensory changes, and difficulty making decisions and solving problems are some of the many challenges related to long-term illness and disability. Physical and psychological trauma can also be risk factors for suicide.

Co-morbid conditions may increase the likelihood that a suicide attempt becomes a completed suicide; for example, if a person with a chronic condition such as hepatitis C swallows a bottle of acetaminophen, they are likely to suffer severe liver damage. By the same token, a person with severe anemia may not survive a suicide attempt involving a significant loss of blood.

Substance Use Disorders

Every year about 650,000 people receive treatment in emergency departments (EDs) following a suicide attempt. More than 40% of these admissions involve drug-related suicide attempts, and many involve a prescription drug or over-the-counter (OTC) medication. Substance use disorders are a strong risk factor for suicide attempts and suicide. Indeed, suicide is a leading cause of death among people who misuse alcohol and drugs (SAMHSA, 2016).

Alcohol misuse or dependence is associated with a suicide risk that is 10 times greater than the suicide risk in the general population, and individuals who inject drugs are at about 14 times greater risk for suicide. Acute alcohol intoxication is present in about 22% of suicide attempts (SAMHSA, 2016). Depression—a common co-occurring diagnosis among people who abuse substances—also confers risk for suicidal behavior (CSAT, 2015).

Did You Know. . .

The number of ED visits for drug-related suicide attempts increased 41% overall from 2004 to 2011 and more than doubled among people age 45 to 64 (Crane, 2016).

A person admitted to the ED at acute risk for suicide and who is also intoxicated by drugs or alcohol should be kept under observation and assessed for suicide risk when no longer intoxicated or in acute withdrawal. Following assessment in the ED, about half of these patients are admitted to the hospital, about a quarter are transferred to another healthcare facility, and slightly less than a quarter are discharged after being treated. About 4% leave against medical advice or die in the ED (Crane, 2016).

Outcomes of ED Visits Involving Drug-Related Suicide Attempt (2004 to 2011)

Source: Crane, 2016.

Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacologic criteria.

Even when a person is in treatment for a substance use disorder, the prevalence of suicidal ideation and suicide attempts remains high. This is also true for those who have at one time been in treatment (CSAT, 2015).

Abstinence is a primary goal of any client with a substance use disorder and suicidal thoughts or behaviors. For most clients abstinence reduces risk, although some individuals remain at risk even after achieving this goal. This can include patients with:

• Independent depression
• Difficulties that promote suicidal thoughts
• Personality disturbances such as borderline personality disorder
• History of trauma (such as sexual abuse)
• Major psychiatric illness (CSAT, 2015)

Did You Know. . .

The number of substances used seems to be more predictive of suicide than the types of substances used.

One of the reasons alcohol and drug misuse significantly affects suicide rates is the disinhibition and impulsivity that occurs when a person is intoxicated. Impulsivity and disinhibition are overarching issues related to suicidal behaviors. In fact, angry impulsivity has been repeatedly identified as a common risk factor. Although impulsivity is found in a wide range of diagnoses, it is highly associated with bipolar disorder, substance abuse, and certain personality disorders, as well as a history of early child abuse (Fawcett, 2012).

Immigrants and Refugees

For people migrating to the United States, stress associated with migration can be a risk factor for suicidal ideation. Ending ties with their country of origin, loss of status and social networks, language barriers, unemployment, financial problems, a sense of not belonging, and feelings of exclusion can lead to depression, anxiety, PTSD, alcohol and drug abuse, loneliness, and hopelessness (Ratkowska & De Leo, 2013).

Refugees, one of the most vulnerable groups of immigrants, may be fleeing war, torture, and persecution, and suffering with PTSD, depression, and anxiety. Lack of adequate preparation, the way in which refugees are received in the destination country, poor living conditions, lack of social support, and isolation add to these vulnerabilities. Refugees may also feel guilty for leaving loved ones at home. The sense of guilt, together with isolation and trauma, may be risk factors for suicide (Ratkowska & De Leo, 2013).

Migration poses a risk not for the families who remain in the country of origin. For example, it has been observed that the next of kin of Mexican emigrants to the United States were at greater risk of suicidal ideation and suicide attempts than Mexicans without a family history of immigration. Immigration can weaken family ties, lead to feelings of loneliness and insecurity, and increase the risk of suicide among family members who remain at home (Ratkowska & De Leo, 2013).

Immigrants from predominantly collectivist societies may face serious problems of adaptation due to a real or perceived lack of social support, a disparity between expectations and reality, and low self-esteem. Many immigrants undergo radical changes in their social status and may also be subject to discrimination. This could be an additional risk factor for suicide, as evidenced by one of the U.S. studies where immigrants’ suicide rates were positively correlated with the negative words used by the majority to describe their ethnic group (Ratkowska & De Leo, 2013).

In most studies conducted in Europe, America, and Australia, the highest risk of suicide was found in immigrants from northern Europe (including the United Kingdom, Ireland, and Finland), and Eastern Europe (especially from Russia and Hungary). The lowest risk was found in immigrants from southern Europe and the Middle East (Ratkowska & De Leo, 2013).

For immigrants from Asian countries, the risk of suicide seems generally low for men but appreciably higher for women. The rates vary not only in relation to the country of origin but also for the gender of the immigrant. For example, in a study conducted in the United States, Asian, black, and Hispanic men had the lowest risk of suicide, while non-Hispanic white and Asian women had higher risk than the host population (Ratkowska & De Leo, 2013).

The high suicide rates among immigrants from Northern and Eastern Europe might be partly explained by the high alcohol consumption typical of these countries. For example, there is a significant correlation between alcohol consumption and suicide in Finland; Finnish immigrants who died by undetermined causes of death in Sweden also tend to have high alcohol levels in their blood. A similar trend was found in Russia, where suicide rates related to alcohol abuse are very high, and among Russian immigrants who died by suicide in Estonia (Ratkowska & De Leo, 2013).

The low rates of suicide among immigrants from southern Europe, the Middle East, and Asia may be due to some protective social factors, such as the strong influence of traditional values, family, and religious beliefs. These countries are more collectivist, have strong family ties, and a strong group identity outside their country of origin. Both in Catholic and Muslim countries, religion may be a strong deterrent to suicide, which is considered a sin in the Catholic religion and is forbidden by Islamic law. The protective role of religion could also depend on the ties with the religious community, which might represent a strong source of social support (Ratkowska & De Leo, 2013).

Among asylum seekers, those at higher risk for suicide are young, male, low income, with past traumatic experiences and lack of social support. Refugees and asylum seekers often have several of these risk factors (Ratkowska & De Leo, 2013).

Documenting Risk

Documentation should describe the gathering of information, whether or not a consultation is needed, a description of the action taken by the healthcare provider to address the patient’s risk, and what steps were taken to follow up. Documentation provides a written summary of any steps taken, along with statements that show the rationale for the plan. The plan should make good sense in light of the seriousness of risk (CSAT, 2015).

Gathering information involves collecting relevant facts. Screening questions should be asked of all new patients when you note warning signs and any time you have a concern about suicide, whether or not you can pinpoint the reason. Inquiries start with open-ended questions that invite the client to provide more information. Followup questions are then asked to gather additional, critical information.

Consultation is a formal process whereby information and advice are obtained from (a) a professional with clear supervisory responsibilities, (b) a multidisciplinary team that includes such people, and/or (c) a consultant experienced in managing suicidal clients who has been vetted by your agency for this purpose. Immediate supervision or consultation should be obtained when clients exhibit direct suicide warning signs or when, at intake, they report having made a recent suicide attempt. Substance abuse relapse during treatment is also an indication for supervisory involvement for clients who have a history of suicidal behavior or attempts.

Taking responsible action means your actions should make good sense in light of the seriousness of suicide risk. Seriousness is defined as the likelihood that a suicide attempt will occur and considers the potential consequences of an attempt. Judgments about the degree of seriousness should be made in consultation with a supervisor or a treatment team, not by a healthcare provider acting alone.

Suicide prevention efforts are ongoing rather than one-time actions requiring consistent followup. A team approach is essential, which requires a healthcare provider to follow up on referrals and coordinate with other providers in an ongoing manner.

The following case example highlights the importance of documentation using the four-step process: (1) gather information, (2) access supervision or consultation, (3) take responsible action, and (4) follow up.