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.
3.1 Protective Factors
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.
3.2 Risk Factors
Risk factors are characteristics, attributes, or exposures within an individual that increase the likelihood of developing a disease or injury. Risk factors can accumulate and increase an individual’s vulnerability to suicidal behavior. Especially for young people, increased risk has been associated with a family history of suicide, exposure to previous suicidal behavior by others, a history of depression, or mental health problems.
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 include:
More directly related to a person’s family history
- A family history of suicide
- A family history of child maltreatment
- High conflict or violent relationships
Other individual risk factors
- Isolation or feelings of isolation
- Feelings of hopelessness
- Impulsive or aggressive tendencies
- Losses, such as of close relationships
- Illness and disability
At the community level:
Conditions that increase risk
- Lack of access to mental health services
- Suicide clusters in the community
- Community violence
Additional community risk factors
- The stress of acculturation
- Historical trauma
- Discrimination
At the societal level, risk factors include:
- Easy access to lethal means
- Certain cultural and religious beliefs
- An unwillingness to seek help because of stigma.
Stigma can be a particularly powerful societal risk factor because it can include labeling, stereotyping, separation, loss of status, and discrimination. When stigma occurs in the context of mental illness, it can have even more harmful than the mental illness itself and can be a risk factor for suicide (Roškar et al, 2022).
Interventions to Reduce Risk |
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Intervention |
Goal or Outcome |
Economic supports |
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Improve access and delivery of healthcare |
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Provide protective environments |
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Promote connectedness |
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Promote coping and problem-solving skills |
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Direct support for people at risk |
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3.2.1 Mental Health
Suicide is overrepresented in people with mental illness although most people with mental health conditions do not commit suicide. Impulsivity (particularly angry impulsivity) and disinhibition are strongly related to suicidal ideation and behaviors. Impulsivity is associated with bipolar disorder, substance abuse, and certain personality disorders as well as a history of early child abuse.
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).
3.2.2 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).
3.2.3 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.
3.2.4 Substance Misuse
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.
3.2.5 Being a Survivor of Human Trafficking
Survivors of human trafficking and sexual violence are at increased risk of developing substance use disorders to cope with the traumatic experience and symptoms of post-traumatic stress disorder. For these individuals, treating the substance use disorder without addressing the PTSD is ineffective. PTSD symptoms frequently reappear when people stop using drugs or alcohol, leading to relapse. Survivors of human trafficking are at higher risk of suicidal ideation, suicide attempts, and suicide (Akee et al., 2024).
3.2.6 Being an Immigrant, Asylum Seeker, Refugee, or ICE Detainee
For immigrants, asylum seekers, and refugees, suicidal ideation and behaviors arise from a complex interaction between vulnerabilities and risk factors. Temporary visa status, exposure to trauma, exposure to detention settings, and social isolation can contribute to increased risk. The term “lethal hopelessness” has been used to describe the increased suicide risk in asylum seekers due to the combination of limited access to mainstream services, financial support, culturally safe healthcare, and working rights (Ingram et al., 2022).
Immigrants migrating to an unfamiliar country lose links with their country of origin and often experience language barriers, a loss of status and social networks, and a sense of inadequacy. Unemployment, financial problems, a sense of not belonging, and feelings of exclusion can negatively affect a person’s desire and ability to enter relationships with others. This can lead to depression, anxiety, post-traumatic stress disorder, and abuse of alcohol or drugs. Feelings of isolation, loneliness, and hopelessness can increase the risk of suicidal behaviors (Ratkowska & De Leo, 2013).
The migration of a family member poses a risk not only for immigrants but also for their families who remain in the country of origin. For example, the next of kin of Mexican immigrants in the U.S. were at greater risk of suicidal ideation and suicide attempts than Mexicans without a family history of emigration. Emigration of a close family member can weaken family ties, cause feelings of loneliness and insecurity, and increase the risk of suicide among family members who remain at home (Ratkowska & De Leo, 2013).
A study of Chinese immigrants in the U.S. found that older adults experiencing linguistic and cultural barriers rely heavily on their adult children to have access to healthcare and social services. Their social networks predominantly consist of family members, and they are isolated from the community. Their perceived burdensomeness to children and their social isolation can lead to suicidal ideation (Li et al., 2022).
Refugees are perhaps the most vulnerable group of immigrants: they are often fleeing war, torture, and persecution, and suffer with PTSD, depression, and anxiety. Lack of adequate preparation, the way in which they are received in the destination country, poor living conditions, and lack of social support and isolation add to these vulnerabilities. Refugees may also feel guilt for leaving loved ones at home or for their death. The sense of guilt, together with isolation and pathologic symptoms due to trauma, can be a strong risk factor for suicide (Ratkowska & De Leo, 2013).
For migrants in U.S. Immigration and Customs Enforcement (ICE) detention, mental healthcare has historically been substandard. ICE detainees suffer from higher rates of anxiety, depression, and post-traumatic stress disorder and are especially susceptible to stressors (Erfani et al., 2021).
Time spent in immigration detention is a particular post-migration stressor. Widespread failures to provide mental healthcare to detainees and critical medical staff shortages put ICE detainees at an increased risk for suicide. Between 2018 and 2020, the proportion of deaths in ICE detention attributed to suicide approximately doubled since cause of deaths were last described in 2015 (Erfani et al., 2021).
3.3 Documenting Risk
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 various aspects of the problem (CSAT, 2017).