Suicidal Ideation: Symptoms, Treatments, & How to Get Help

Passive vs Active Suicidal Ideation

Having thoughts of suicide is scary and upsetting, but not uncommon. Suicidal ideation actually describes a spectrum of thoughts that range from fleeting and “passive” to persistent and “active.” Active suicidal ideation is more serious than passive suicidal ideation because it means that a person has an urge, intention or specific plan to commit suicide.

Having a specific plan to commit suicide places people at higher risk of committing or attempting to commit suicide. Research estimates that 56% people who have a suicide plan make an attempt, versus 15.4% of people without a plan.⁸ Passive suicidal ideation describes more generalized forms of ideation or wanting or wishing to die but not having a plan or intention to commit suicide, and is likely much more common than active forms of ideation.

Overall Prevalence of Suicidal Ideation, Plans & Attempts

Large studies and national surveys have helped researchers develop the following estimates on the prevalence of suicidal ideation, plans, and attempts:^8,9

• 9.2% of adults report having thoughts of suicide at some point in their lives
• 4.8% of US adults had “serious” thoughts of suicide in 2019
• 1.4% with serious thoughts of suicide made a suicide plan
• 0.6% who had serious thoughts of suicide made an attempt
• 1 of every 31 suicide attempt in 2019 was fatal
• Suicide is the 10th leading cause of death in the US

Of note, it is highly likely that the number of people who have had passive or active thoughts of suicide is underreported. Stigma and fear of psychiatric intervention continue to prevent many people with suicidal thoughts from reporting them. Assuming that suicidal ideation is underreported also makes it likely that a smaller percentage who experience thoughts of suicide act on them. More statistics on suicide rates can be found here.

Teens, young adults, and college students are at the highest risk for suicide. The risk for suicide significantly decreases after the age of 25 and continues to lower until it levels off in midlife, and has a much more moderate decline in later life.⁹ Females attempt suicide more than do men, but men (especially White men) are more likely to use more lethal methods and are three times as likely to die from a suicide attempt. In 2018, 50% of all fatal suicides involved a firearm.¹

Signs of Suicidal Ideation: What to Watch Out For

Because there are multiple causes, there are no certain warning signs of suicide that are consistently noted. Suicidality is often linked to external events that are stressful and traumatic, but this is not always the case. Some people with untreated or unmanaged mental health conditions like bipolar disorder, depression, or a drug or alcohol dependence are at higher risk for suicidal ideation, even when there is no external cause.

Some of the signs that can indicate suicidal ideation include:¹

• Appearing more sad, tired, and disconnected
• Moodiness, increased irritability or sensitivity
• Social isolation and withdrawal
• Not engaging in previously enjoyed activities
• Having a “flat” affect or not showing emotions
• Changes in eating or sleeping patterns
• Talking about being a burden
• Talking about feeling trapped
• Hopelessness or helplessness that things can improve
• Feeling completely overwhelmed or stressed
• Talking about death, suicide, or about life being pointless
• Increased use of drugs or alcohol
• Giving away possessions
• Saying goodbye to loved ones
• Self-hatred, lack of self-worth or shame

In children and teens, warning signs can show up differently and may occur in response to different kinds of external triggers. Suicidal ideation in children or teens is more likely to occur in response to social stressors like being the victim of bullying, a breakup, or a conflict with peers. Gay, lesbian, bisexual and transgendered kids, teens, or young adults are also at higher risk for suicidality.

In addition to the signs listed above, some additional warning signs that may indicate a child or teen is considering suicide include:^1,6

• Finding suicide plans, notes, or journal entries
• Searches online for suicide methods
• Concerning posts on social media about death or suicide
• Concern from the school about behavior, mood, or performance
• Learning that the child/teen was the victim of bullying
• Drastic changes in appearance/dress/music/media preferences
• Conflict with friends or having few close friends
• Talking about feeling misunderstood
• Behavioral outbursts that are abnormal for the child/teen

Symptoms of Suicidal Ideation

Suicidal ideation is not a diagnosable condition, but can be an indicator of an underlying condition. Suicidal ideation is most closely linked with major depressive disorder and Substance/Alcohol Use Disorders. People with Major Depressive Disorder and Substance/Alcohol Use Disorders are the most likely to report suicidal ideation and make suicide attempts.^8,4 All mental health and substance use disorders are diagnosed using standardized criteria from the DSM-5.

The DSM 5 symptoms for Major Depressive Disorder are:²

Experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either depressed mood or loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Substantial weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
4. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
5. Fatigue or loss of energy nearly every day.
6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Notably, to receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must not be a result of substance misuse or another medical condition.

The DSM 5 Symptoms for a Substance or Alcohol Use Disorder are:²

A pattern of problematic and compulsive drug use and 2 or more of the following:

• More/longer use: You have started to use larger amounts or use the substance for longer amounts of time than intended.
• Hazardous use: You have used the substance in ways that are dangerous to yourself and/or others, i.e., while working or driving a vehicle.
• Social or interpersonal problems related to use: Substance use continues after it has caused problems or conflicts in important relationships
• Neglected major roles to use: You have failed to meet your responsibilities at work, school, or home because of substance use.
• Withdrawal: When you stop using the substance, you experience uncomfortable or unpleasant physical or psychological withdrawal symptoms.
• Tolerance: You have built up a tolerance to the substance and it is no longer effective at the original dose.
• Repeated attempts to control use or quit: You’ve tried to cut back or quit but haven’t been successful.
• Excessive time spent using: You spend a lot of your time using the substance, thinking about using the substance, or recovering from the effects of using the substance.
• Physical or psychological problems related to use: Your substance use has led to physical health problems, such as liver damage or lung cancer, or psychological issues, such as depression or anxiety.
• Activities given up to use:You have skipped activities or stopped doing activities you once enjoyed in order to use the substance.
• Craving: You have experienced cravings for the substance.

Causes of Suicidal Ideation

There is no simple or singular cause for suicidal ideation, but extensive research has been conducted to determine factors that increase the risk of suicidal thoughts and behaviors. Psychological factors are believed to play the most significant role in suicidality, with some research estimating that 90% of those who commit suicide experienced with a mental health condition.¹⁰

The conditions most closely linked to suicide are Substance Use Disorders (inluding alcohol) and Major Depressive Disorder. Among those with these conditions, those with more severe symptoms appear to be at highest risk. Bipolar is also closely correlated with suicide.⁴

Other mental illnesses and psychological factors related to heightened risk for suicidal ideation and attempts include:^1,4,7,8

• Attention Deficit Disorder with Hyperactivity (particularly adults)
• Post-Traumatic Stress Disorder (especially veterans)
• Eating disorders (especially anorexia)
• Traumatic Brain Injuries
• Schizophrenia
• Co-occurring anxiety and depression
• Personality disorders
• Adverse Childhood Experiences (abuse or neglect)
• Insomnia or persistent sleep problems
• Heightened levels of stress or trauma exposure
• Legal or financial stress
• A relationship ending
• Chronic health issues or chronic pain
• Adverse effects of certain medications (i.e., antidepressants can cause or worsen suicidal thoughts in children or young adults)
• Having attempted suicide in the past
• Having a history of self-harming behavior (i.e. cutting)
• Recent inpatient psychiatric hospitalization

The general theme noted in the research is that individuals considering suicide or who have attempted suicide are experiencing high levels of stress and psychological suffering. The emotional distress these individuals are experiencing causes them to feel trapped, helpless, and hopeless.

It is likely that many of these individuals, even those who have acted on suicidal ideations, are seeking a way to escape and end their suffering rather than actually wanting to die. On a related note, research shows that of people who survive a suicide attempt, 85-95% will go on to engage in life.¹

Diagnosing & Treating Suicidal Ideation

When a person discloses thoughts of suicide to a healthcare professional, the healthcare professional will conduct a suicide risk assessment.

This is a short series of questions to screen for suicide risk and can include questions like:⁵

• How long have you had these thoughts?
• How often do you have these thoughts?
• Do the thoughts come in response to certain upsetting situations?
• Have you ever acted on thoughts like these?
• Do you intend or want to act on these thoughts?
• Have you ever made a plan of how you would end your life?
• Do you have any weapons in your home?
• Do you have symptoms of depression or another condition?
• Do you use alcohol or drugs?

While these questions may seem invasive, they are asked to help better understand your suicide risk and determine the most appropriate treatment for you. In some cases, you may be asked to create a safety or “no-harm” contract with the provider. This contract outlines steps you commit to taking to reduce your suicide risk.

Often, people who have suicidal ideation are recommended for additional treatment, which may include the following:

Outpatient Counseling

Outpatient counseling is provided by a licensed mental health or addiction counselor, a social worker, or a psychologist. Outpatient counseling can be provided in individual, couples, or group contexts and generally involves 1-2 sessions a week lasting about an hour. Some of the types of counseling that have the most evidence in treating suicidality include Dialectical Behavioral Therapy and Cognitive Behavioral Therapy.¹

Psychiatric Medication

Medication for mental health conditions is often prescribed by a physician, psychiatrist, a nurse practitioner, or other licensed professional with specialized experience in mental health. Medication is sometimes recommended in addition to other forms of treatment (like counseling) to help stabilize or reduce symptoms of an underlying condition like depression or anxiety.

Inpatient Hospitalization

In some cases, you may be recommended to enter inpatient treatment. Inpatient treatment is a hospital-like setting where you can receive short-term stabilization. Inpatient hospitalization often includes a combination of medication adjustment, group and individual counseling, therapeutic programs, and case management.

Inpatient Detox/Rehab

Inpatient detox or rehab facilities are inpatient centers that specialize in helping people struggling with drug, alcohol, or behavioral addictions. These facilities are staffed with doctors and counselors who specialize in addiction treatment. Sometimes, inpatient care is needed to help people safely detox and withdraw from a drug they have become dependent on, and other times it is needed to help establish sobriety

How to Get Help for Suicidal Ideation

If you are struggling with suicidal ideation and are in need of support, resources, or immediate help, you can connect with one or more of the resources listed below.

• American Foundation for Suicide Prevention 24/7 hotline: 1-800-273-8255
• Substance Abuse and Mental Health Association 24/7 hotline: 1-800-662-4357
• Emergency support: In case of an emergency situation you can reach out to:
  • Call 211 (Helpline for resources and services in your community)
  • Call 911 for emergency first responders (police, fire dept., or ambulance)
  • Poison control (for intentional or accidental overdose or ingestion of dangerous substance) 1-800-222-1222
  • Go to the nearest emergency room for immediate medical emergencies

How to Help a Loved One Who is Considering Suicide

If you know or suspect that a friend, family member, or someone else you care about is struggling with suicidal ideation, there are things you can do to intervene and help. It is important to begin with the least extreme option and only consider more serious interventions if they are warranted.^1,3

1. Ask Directly

It can feel awkward or uncomfortable to initiate a conversation about suicide, but doing so is often the best way to identify whether a person is considering suicide. If they admit to suicidal ideation, proceed to the next step. If they deny thoughts of suicide, let them know you are there to talk or support them. Leaving the door open to talk about suicide may encourage them to reach out to you later on if they need to.

2. Listen Empathetically

If they do admit to having suicidal thoughts, try not to panic or react negatively to them, and instead express concern and offer to just listen. People who are considering suicide often feel alone and like no one cares about them so simply listening and being compassionate can make a big difference. In fact, trained professionals who answer suicide hotlines are usually trained to listen empathetically, as opposed to trying to console the person or give them advice.

3. Ask How You Can Help

After listening, the next best thing to do is to ask the person how you can help them. If they are unsure, offer to help by staying with them to listen or talk until they feel a little better. You could also offer to help by finding a counselor they can call or even offering to drive them to the hospital. If they don’t want you to stay and you are still worried they might act on their thoughts of suicide, you may need to take additional action.

4. Express Concern & Encourage Treatment

While it is best to have the person ask for or accept the help you offer, sometimes they will be resistant to your help. If you have reason to be worried about them acting on suicidal thoughts, express your concern openly to them. Let them know that you feel worried and don’t want to leave them alone until you feel sure they are okay.

Ask them if you can call someone else they feel more comfortable with and ask to stay until the person arrives. If there are imminent safety concerns (like a gun in the home or medication they say they plan to overdose on), ask to take these items for safekeeping. Encourage them to take steps to get treatment or at least set up an appointment with a counselor or other professional.

5. Involve Authorities

In most cases, this step is not necessary but if you continue to have reasons to be strongly concerned about their safety, there are additional steps you can take. One option is to call the police and request for them to do a welfare or wellness check, which is when the police stop by to ensure a person is safe.

If you are concerned that a person has ingested drugs or overdosed, call 911 immediately. In extreme cases, it is also possible to go to the magistrate and file an involuntary commitment order, which will result in the person being taken (even against their will) for a mandatory psychiatric evaluation. If they are deemed to be at risk of hurting themselves or others, they can be committed to inpatient treatment without their consent.

6. Follow-Up

Regardless of what steps you needed to take to help or intervene with a person who is suicidal, it is important to follow up with them. Consider a phone call or visit with them to let them know you have been thinking about them, that you still care, and that you are there for support.

How to Get Help for a Child or Teen

If you are a parent and are worried that your child or teen is having thoughts of suicide, the steps outlined above are still often the best course of action but these may need to be slightly adjusted. Parents have a responsibility for the welfare and well-being of their children and this may mean parents need to take more direct action on behalf of their child.

Depression is very common in teens, with nearly one of three high schoolers in the US reporting a depressive episode. Female teens are especially susceptible and have a doubled risk of depression, suicidal ideation, and suicide attempts compared with their male peers. ⁶ Early identification and treatment of depressive symptoms in teens can help to prevent suicidal ideation.

Parents can and should initiate treatment for their child or teen if they have reason to suspect suicidal thoughts or behavior. Depending on the severity of the concern and risks, treatment could include outpatient or inpatient counseling and possibly psychiatric medication. Children and teens tend to have better treatment outcomes when parents are actively involved in their treatment.

Finding a counselor or treatment provider who is a good match for your child or teen is important because they are unlikely to open up or engage in treatment with a provider they do not feel comfortable with. Any child or teen who has expressed thoughts of suicide should be closely monitored even after they start treatment. Additional safeguards should be put into the place and include things like ensuring the child cannot access weapons, sharp items, alcohol, and prescribed or non-prescribed medications.³

If a parent notices warning signs, they should inform the treatment providers immediately and consult about the appropriate course of action. In some cases, it may be necessary to initiate higher levels of care including intensive outpatient treatment or inpatient hospitalization. In addition to formal treatment, encouraging a healthy lifestyle (proper sleep, exercise and nutrition) and enriching social and extracurricular activities are also important components of addressing suicidality.

Seven Suicide Prevention Strategies for People with Suicidal Ideation

Suicidal ideation is usually an indication of unmanaged mental illness, addiction, or a sign of systemic problems or stress within a person’s life. If you are experiencing suicidal ideation, consider the following seven actions and activities:^1,3

1. Seek Professional Treatment

Seek out counseling, mental health treatment and/or medication to address underlying mental health or dependency issues. If the root problem is a specific stressor or problem (like divorce, grief, or unemployment), consider finding a counselor who specializes in treating this issue.

2. Use Your Support System

Maintain and utilize your support system which may include friends, family, and even professional support people (like a counselor). If you don’t have a support system, work on building one by contacting old friends or family members, deepening your relationship with coworkers or associates, or starting a new activity, meetup, or even a support group. Strong supportive relationships are good for all aspects of your physical and mental well-being.

3. Enjoy Your Free Time

Spend your time in meaningful ways by engaging in hobbies or activities you enjoy, attending religious services, volunteering for a cause you believe in, or actively working to learn a new skill or complete a project. Work to make your life more meaningful and fulfilling and to spend your time in ways that align with the things in life you care about most. Setting and working towards goals also helps you feel more positive and hopeful about the future, and more in control of your life.

4. Stay Positive

Don’t “participate” in negative, upsetting or suicidal thoughts. While you cannot help when a thought pops into your head, you can choose how much you participate in it by repeating it, ruminating on it, or finding evidence to support it. Even trying to disprove it, force it out, or replace it with a different thought is a form of participation and often is not only ineffective but can even get you more stuck in the thought. Mindfulness and meditation are great practices that can help you learn to distance and reduce participation in unhelpful thoughts.

5. Don’t Avoid Feelings

Don’t try to stop, get rid of, fix, or avoid your feelings. Like thoughts, feelings can be difficult and uncomfortable, but they can’t force or prevent you from making good decisions. Often, the ways people respond to their emotions is more problematic than the emotion itself (i.e., using drugs when sad, lashing out when mad, or skipping work when anxious). Instead of investing time in trying to fix, stop, control, or avoid your emotions, work on trying to respond differently to them, and specifically work on trying to make good decisions even when they show up. Doing so will help you feel more in control of your actions and choices, even during times when you are upset.

6. Self-Care

Practice self-compassion and improve self-care. Self-criticism, shame, and self-hatred are often contributing to mental health issues and suicidal thoughts. Practice self-compassion by changing your self-talk to mimic the way someone who cares about you would talk to you. Because actions speak louder than words, also work on treating yourself more kindly by prioritizing things that are good for your physical and mental health. Be consistent with these self-care routines (including proper sleep, nutrition and exercise and also use of emotional outlets like journaling or support groups).

7. Stay Connected With the Part of You That Wants to Live

People who have thoughts of suicide almost always have a part of them that wants to live, but this part has been overshadowed by the part of them that is suffering and feels trapped. Work on tapping into your reasons for living, including the people who you care about, the parts of life that are fulfilling, and the plans and goals that make you excited about the future. The more attuned you are to these reasons for living, the less affected you will be if thoughts of suicide arise.