A protective factor is anything that makes it less likely for a person to develop a disorder. A risk factor is anything that makes it more likely for a person to develop a disorder or predisposes a person to high risk for self-injurious behaviors.
Protective factors—both personal and social—can buffer a person against the risk of suicide (Stone, 2017). The availability of appropriate support services—safety nets—can strengthen a person’s protective factors, whereas a lack of resources may increase a person’s risks.
Protective personal factors include:
- A sense of identity and belonging
- Good self-esteem, and an optimistic view of life
- Moral objections to suicide
- Problem-solving and coping skills, e.g., the ability to resolve conflicts, and good impulse control
- Involvement with cultural, spiritual, or religious practices
- Self-care, e.g., understanding the importance of health and wellness, seeking help when needed, engaging in constructive and enjoyable leisure activities
Protective social factors include:
- Strong interpersonal bonds and friendships
- Good community support
- A safe and stable home environment
- Strong intimate relationships
Being responsible to others, employment, and child-rearing responsibilities can also be protective social factors.
[An additional source for the information about risk factors is WSDOH, 2016.]
Predicting suicide risk is a key challenge in suicide prevention, with risk misclassification having serious consequences—both “false negatives” who go on to self-harm without being identified and “false positives”—who are monitored, screened, or treated unnecessarily (McKernan et al., 2018). Increased risk is associated with a number of factors, many of which are present in a large number of people, making it difficult to identify who may be at risk for suicidal behaviors.
The strongest individual risk factors for suicidal ideation and behaviors include:
- History of mental disorders, especially clinical depression
- History of alcohol and substance abuse
- One or more previous suicide attempts
- Unwillingness to seek help
Additional risk factors for an individual, some of which are directly related to a person’s family history, include:
- Family history of suicide
- Family history of child maltreatment
- Isolation or feelings of isolation
- Feelings of hopelessness
- Impulsive or aggressive tendencies
- Losses, such as of close relationship(s)
- Illness and disability
- High conflict or violent relationships
At the community level, various conditions present risks, such as:
- Lack of access to mental health services
- Suicide clusters in the community
- The stress of acculturation
- Community violence
- Historical trauma
Societal risk factors include:
- Easy access to lethal means
- Cultural and religious beliefs
- Unwillingness to seek help because of stigma
Stigma is characterized by labeling, stereotyping, separation, loss of status, and discrimination. Especially when it occurs in the context of mental illness, stigma can have even more harmful effects than the mental illness itself and can be a risk factor for suicide (Roškar et al, 2022).
Interventions to Reduce Risk
Goal or Outcome
Household financial security
Improve access and delivery of health care
Mental health coverage in health insurance policies
Providers available in underserved areas
Provide protective environments
Reduce access to lethal means
Reduce excessive alcohol use
Peer norm programs
Engagement in community activities
Promote coping and problem-solving skills
Parenting skill and family relationship programs
Direct support for people at risk
Gatekeeper training and crisis intervention
Treatment to prevent re-attempts
Post-mortem forensic reviews suggest that most suicide decedents have identifiable mental illness, though only about one-half had received a mental health diagnosis in the year prior to their death. The under-recognition of mental conditions seriously limits the potential to identify and appropriately treat individuals at risk for suicide (DVA/DOD, 2019).
In people with a mental illness, the odds for suicide related to severe depression, schizophrenia, and bipolar disorder are approximately 3 to 10 times greater than that of the general population, with a higher increased risk in males than females. Despite this, mental illness is a poor predictor of suicidal ideation and behaviors since suicide does not occur in 95% to 97% of all cases (Fosse et al., 2017).
Access to Lethal Means
Access to lethal means is a risk factor for suicide. Lethal means are objects, substances or actions that might be used in a suicide attempt. This includes items such as firearms, poisons, alcohol or drugs, and actions such as jumping from a bridge or building (DSPO, 2020).
Reducing access to lethal means includes:
- Restricting access to firearms.
- Promoting safe storage of firearms and other lethal products.
- Reducing access to potentially toxic medications.
Household gun ownership is a significant positive predictor of both homicides and suicides. In 2019, 50% of the more than 47,000 suicides in the U.S. involved firearms (Kivisto, 2022). Firearms are deadly and individuals who attempt suicide using firearms are more likely to die in their attempts than those who use less lethal methods (HHS, 2012, latest available).
Among nurses and physicians, poisoning is the most common lethal means used in suicide. Both nurses and physicians were more likely to have antidepressants, benzodiazepines, and barbiturates identified in the results of the toxicology examination. The higher presence of barbiturates at death is notable because of their infrequent clinical use (Davis et al., 2021).
Reducing access to lethal means used in suicide attempts and suicide is now considered a key component in a comprehensive suicide prevention strategy and has been shown to be effective in reducing suicide death rates (DVA/DOD, 2019).
Increased Risk Related to Medical and Physical Issues
Physical illness is a commonly overlooked risk factor for suicide. It can cause significant stress, feeling like a burden to family, potential loss of employment, excessive medical bills, and feeling alone and isolated. These powerful stressors can increase suicidal thoughts in vulnerable patients, particularly individuals who have a history of suicidal thoughts or behaviors (Horowitz et al, 2018).
Certain medical conditions are associated with an increased risk for suicidal ideation and behaviors. This can include chronic pain, cognitive changes that make it difficult to make decisions and solve problems, and the challenges related to long-term conditions and illnesses.
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.
Trauma is also a risk factor for suicide. Although some people who experience trauma move on with few symptoms, many—especially those who experience repeated or multiple traumas—suffer a variety of negative physical and psychological effects. Trauma exposure has been linked to later substance abuse, mental illness, increased risk of suicide, obesity, heart disease, and early death.
Suicide is a leading cause of death among people with substance use disorders. Compared to the general population, individuals treated for alcohol misuse or dependence are at about 10 times greater risk for suicide; people who inject drugs are at about 14 times greater risk for suicide (CSAT, 2017).
Depression—a common co-occurring diagnosis among people with substance use disorders—can confer additional risk. People with substance use disorders often seek treatment at times when their substance use difficulties are at their peak—a vulnerable period that may be accompanied by suicidal thoughts and behaviors (CSAT, 2017).
Substance Use Disorders
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) no longer uses the terms substance abuse and substance dependence. Rather it refers to substance use disorders—defined as mild, moderate, or severe—determined by the number of diagnostic criteria met by an individual.
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.
The most common substance use disorders in the U.S. include:
- Alcohol Use Disorder (AUD)
- Tobacco Use Disorder
- Cannabis Use Disorder
- Stimulant Use Disorder
- Hallucinogen Use Disorder
- Opioid Use Disorder
Even when someone with a substance use disorder is in treatment, the prevalence of suicidal ideation and suicide attempts remains high; there is a significant prevalence of suicide among those who have at one time been in treatment for a substance use disorder. Suicidal thoughts and behaviors are also a significant indicator of other co-occurring disorders (CSAT, 2017). The number of substances used seems to be more predictive of suicide than the types of substances used.
Documenting risk involves gathering information, noting warning signs, and initiating appropriate screening and referrals. Good documentation promotes safety, coordinates care, and establishes a solid medical and legal record. Documentation provides a written summary of any steps taken, along with a statement of conclusions that shows the rationale for the plan. The plan should make good sense relative to the seriousness of risk (CSAT, 2017).
Good documentation also supports a team approach, as it requires follow up on referrals and coordination with other providers. Effective suicide prevention is comprehensive: it requires a combination of efforts that work together to address different aspects of the problem (CSAT, 2017).