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. Both protective and risk factors can include biologic, psychological, or social factors in the individual, family, and environment.
Protective factors, or those influences that buffer against the risk for suicide, can be found across different levels of society. Protective factors include effective coping and problem-solving skills, moral objections to suicide, strong and supportive relationships with partners, friends, and family; connectedness to school, community, and other social institutions; availability of quality and ongoing physical and mental healthcare, and reduced access to lethal means. Protective factors can either counter a specific risk factor or buffer against a number of risks associated with suicide (Stone, 2017).
Protective social factors include strong interpersonal bonds and friendships and good community support. A safe and stable home environment is critically important, including a strong marriage or other intimate relationship. Being responsible to others, employment, and child-rearing responsibilities can also be protective factors.
Personal factors are also protective. A sense of belonging, a sense of identity, and good self-esteem, along with and optimistic outlook are important. Good problem-solving skills, the ability to resolve conflicts, and good impulse control are strong protective factors. Other personal protective factors include:
- Seeking help when needed
- Being involved with cultural, spiritual, or religious practices
- Engaging in constructive and enjoyable leisure activities
- Understanding the importance of health and wellness
Access to healthcare (including mental health services) is also a protective factor, including care for substance use disorders.
Household financial security
Access and delivery of care
Mental health coverage in health insurance policies
Providers available in underserved areas
Reduce access to lethal means
Reduce excessive alcohol use
Peer norm programs
Engagement in community activities
Coping and problem-solving skills
Parenting skill and family relationship programs
Support people at risk
Gatekeeper training and crisis intervention
Treatment to prevent re-attempts
Although it is difficult to predict who will attempt suicide, increased risk is associated with suicidal ideation or plans, non-suicidal self-injurious behaviors, and suicide attempts (Fosse et al., 2017). Two of the strongest predictors of suicide risk are mental illness and substance abuse.
Attempts to explain, predict, and prevent suicide are limited due to its statistical rarity—suicide is exceedingly rare in comparison to associated risk factors. There are a great many people who abuse alcohol, the majority of whom do not commit suicide; hence the positive predictive value of these risk factors is low.
Increased risk has been associated with gender, lack of support systems, genetic liability, childhood experiences, and the availability of lethal means. Individuals at a greater risk for completed suicide have been found to be male, older, and impulsive, have multiple physical ailments, a history of prior suicide attempts, psychiatric illness, violence, or a family history of suicide (Hassamal et al., 2015).
Certain groups have higher suicide attempt or completion rates than the general population. This can include veterans, members of the armed forces, and their families; people living in small, rural communities, especially people from areas with higher poverty and lower education levels; members of certain racial and ethnic minority groups such as Latina youth and American Indians and Alaska Natives; and LGBTQ populations, particularly youth who have been rejected by their families (WSDOH, 2016).
Other groups thought to be at higher risk for suicidal ideation and completed suicides include:
- People who are (or have been) institutionalized
- Those who have been victims of violence, or are homeless
- People who have had contact with criminal justice and child welfare systems
- People with substance abuse disorders (WSDOH, 2016)
Post-mortem forensic reviews suggest that most suicide decedents have identifiable mental illness, though only about one-half of the decedents had received a mental health diagnosis in the year prior to their death. A large proportion of suicides could be avoided with effective treatment of mental disorders, although 50% to 75% of those in need receive inadequate treatment. The under-recognition of mental conditions seriously limits the potential to identify and appropriately treat individuals at risk for suicide (DVA/DOD, 2019).
Risk Factors for Suicide
Suicide is overrepresented in people with mental illness. The odds for suicide in severe depression, schizophrenia, and bipolar disorder are approximately 3 to 10 times 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 behavior since suicide does not occur in 95% to 97% of all cases (Fosse et al., 2017).
In psychiatric inpatients, an array of risk factors for suicide has been identified. A person admitted for inpatient treatment in a specialized mental health facility has a 50- to 200-times increased suicide risk 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 and deliberate self-harm
- Family history of suicide
- Suicidal ideation
- Depression, hopelessness
- Social or relationship problems (Fosse et al., 2017)
In addition to the risk associated with alcohol and substance abuse, a poor social network and social withdrawal, command hallucinations, delusions, diagnosis of mental disorders other than depression are thought to increase risk. This can include bipolar disorder and schizophrenia, coexisting significant physical illness, family history of mental illness, multiple admissions to inpatient treatment, unplanned discharge, and prescription of antidepressants (Fosse et al., 2017).
Impulsivity (especially angry impulsivity) and disinhibition are strongly related to suicidal ideation and behaviors. Impulsivity is highly associated with bipolar disorder, substance abuse, and certain personality disorders as well as a history of early child abuse.
Illness, stressful life events, and certain medical conditions increase vulnerability and are associated with an increased risk for suicidal ideation and behavior. This can include chronic pain, cognitive changes that make it difficult to make decisions and solve problems, and the challenge related to long-term conditions and limitations (HHS, 2012, latest available).
Trauma can also be a risk factor for suicide. Although some individuals 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.
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.
Suicide is a leading cause of death among people who abuse alcohol and drugs. Compared with the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk for suicide; people who inject drugs are at about 14 times greater risk for suicide. Depression—a common co-occurring diagnosis among people who abuse substances—also confers risk for suicidal behavior. 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, which are defined as mild, moderate, or severe to indicate the level of severity, which is 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 Disorde (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 substance abuse treatment. Suicidal thoughts and behaviors are also a significant indicator of other co-occurring disorders (CSAT, 2017).
The disinhibition that occurs when a person is intoxicated with alcohol or drugs significantly affects suicide rates. The number of substances used seems to be more predictive of suicide than the types of substances used (SAMHSA, 2016).
Immigrants, Asylum Seekers, Refugees, and ICE Detainees
Immigrants who migrating to an unfamiliar country lose links with their country of origin and often experience a loss of status and social network and a sense of inadequacy because of language barriers. Unemployment, financial problems, a sense of not belonging, and feelings of exclusion affect a person’s desire and ability to enter into relationships with others. This can lead to a variety of psychiatric disorders such as 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).
Migration 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).
Immigrants from predominantly collectivist societies may have difficulty adapting to a non-collectivist culture. Many undergo radical changes in their social status and may also be subject to discrimination, which ca be an additional risk factor for suicide (Ratkowska & De Leo, 2013).
A study of Chinese immigrants in the U.S. found that older adults experience linguistic and cultural barriers and 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 may lead to suicidal ideation (Li et al., 2022).
For asylum seekers and refugees, suicide is largely unpredictable and arises from a complex interaction between many vulnerabilities and risk factors in a person’s life. Factors found to contribute to suicide risk among refugees and asylum seekers include temporary visa status, exposure to trauma, exposure to detention settings, and social isolation. 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).
Refugees are perhaps the most vulnerable group of all immigrants: they are often fleeing war, torture, and persecution, and suffering 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 usually add to these vulnerabilities. Refugees may also feel guilty for leaving the loved ones at home or for their death. The sense of guilt, together with isolation and pathologic symptoms due to trauma, may 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 that may exacerbate underlying mental health conditions. Widespread failures to provide necessary mental healthcare to detainees and critical medical staff shortages put ICE detainees at an increased risk for suicide. A recent study reported that 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).
Diagnostic Dilemma: Psychosis or Post Traumatic Stress Disorder
A 32-year-old Black African, Muslim woman with a history of both PTSD and psychosis presented to mental health services for the first time with a history of auditory and visual hallucinations, persecutory delusions, suicidal ideation, recurring nightmares, hyper-arousal, and insomnia. She reported seeing blood on the walls, men in white following her, and hearing voices saying that some men were coming to get her. These symptoms were worse at night. She became very distressed and troubled to the point of wanting to end her life.
Her background history suggested co-morbid PTSD. Twelve years ago, she saw her family (parents, sisters, and brother) being killed during the civil war in her birth country in Africa. Her clinical PTSD symptoms, such as the recurring nightmares, hyper-arousal, and insomnia, began shortly afterwards. Eight years later, she came to the United Kingdom as an asylum seeker. During her first few years in the UK, she had no social support, was unable to speak English, experienced homelessness and was unsuccessful in gaining asylum. Her auditory and visual hallucinations and persecutory delusions started at this time. A few months before her first contact with mental health services, her psychotic symptoms and PTSD features became more frequent and intense. With no stable relationship she became pregnant and visited her general practitioner who referred her to our first-episode psychosis unit.
Upon admission, she presented as well-kempt, yet she appeared distressed. She was withdrawn and quiet and there was some delay in her responses to questions. She was tearful and her mood was low but reactive. She described vivid and clear auditory and visual hallucinations and persecutory delusions. Her medical psychiatric, personal, and family histories were unremarkable. A physical examination, neurological examination and brain magnetic resonance imaging (MRI) scan were normal. The results of our routine blood investigations were in the normal range, and a pregnancy test was positive. At our clinical interview, she clearly fulfilled the criteria for PTSD and psychotic disorder not otherwise specified.
Because of the intensity of her symptoms, her distress and suicidal ideation, our mental health team recommended ongoing hospitalization. She was started on trifluoperazine* (5 mg/day) and cognitive-behavioral therapy for psychosis. She also started a prenatal follow-up. She self-reported a partial improvement in her clinical picture and her psychotic symptoms gradually resolved over a three-week period, although they occasionally resurfaced when she was under stress or whenever her medication compliance lapsed. She was discharged from hospital and is now living in temporary accommodation funded by local services and waiting for her asylum re-application to be processed. She continues to have ongoing PTSD symptoms associated with the initial tragic event as persistent remembering of the stressor event with recurring and vivid memories, nightmares, hyper-arousal and initial insomnia. She also avoids circumstances resembling the initial stressor event, such as wars and violence.
*Trifluoperazine (Stelazine): a typical antipsychotic primarily used to treat schizophrenia. It is part of a class of drugs called phenothiazines.
Source: Coentre & Power, 2011.
Good documentation promotes safety, coordinates care, and establishes a solid medical and legal record. Documentation includes providing 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 in light of the seriousness of risk (CSAT, 2017).
Gathering information involves collecting relevant facts. Screening questions should be asked of all new clients when you note warning signs and any time you have a concern about suicide, whether or not you can pinpoint the reason. Inquiries about suicidal ideation and attempts should start with an open-ended question that invites the client to provide more information. Followup questions are then asked to gather additional, critical information. Routine monitoring of suicide risk should be a basic standard in all substance abuse treatment programs (CSAT, 2017).
Consultation is a formal process whereby information and advice are obtained from (1) a professional with clear supervisory responsibilities, (2) a multidisciplinary team that includes such people, and/or (3) a consultant experienced in managing suicidal clients who has been vetted by your agency for this purpose. Do not judge the seriousness of suicide risk or try to manage it on your own unless you have an advanced mental health degree, specialized training in suicide risk managements, and it is understood by your agency that you are qualified to manage such risk independently (CSAT, 2017).
A useful guiding principle in taking responsible action is that 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 the potential consequences of an attempt. Judgments about the degree of seriousness of risk should be made in consultation with a supervisor or a treatment team, not by a healthcare provider acting alone (CSAT, 2017).
Suicide prevention efforts are not one-time actions. They should be ongoing because suicidal clients are vulnerable to a recurrence of risk. A team approach is essential, as it requires you to follow up on referrals and coordinate with other providers in an ongoing manner. Effective suicide prevention is comprehensive: it requires a combination of efforts that work together to address different aspects of the problem (CSAT, 2017).
Documenting Fernando, Iraqi War Veteran
The following is from a progress note for Fernando, a 22-year-old Hispanic male and Iraq war veteran who was doing well in treatment for dependence on alcohol and opiates but had missed his group therapy sessions and not returned phone calls for the past 10 days. This situation occurred in a substance abuse clinic within a hospital and required immediate supervision and interventions of high intensity.
Step One: Gather Information
Fernando came in, unannounced, at 10:30 a.m. today and reported that he relapsed on alcohol and opiates 10 days ago and has been using daily and heavily since. Breathalyzer was 0.08, and he reported using two bags of heroin earlier this morning. He reported that he held his loaded rifle in his lap last night while high and drunk, contemplating suicide.
Step Two: Access Supervision or Consultation
Upon consultation with a supervisor, it was determined that emergency intervention was needed because of Fernando’s intense substance use, suicidal thoughts with a lethal plan, and access to a weapon. Immediate supervision and consultation were obtained because Fernando exhibited direct suicide warning signs. His reported substance abuse relapse during treatment was also an indication for supervisory involvement.
Step Three: Take Responsible Action
At 11:00 a.m., a hospital security guard and a clinician escorted Fernando to the ED, where he was checked in. He was cooperative throughout the process.
Step Four: Follow Up
Dr. McIntyre, the ED physician, determined that Fernando required hospitalization. He is currently awaiting admission. The person who did the initial evaluation agreed to follow up with the hospital unit after he is admitted and will raise the issue of his access to a gun.
Source: CSAT, 2017.