Suicide is, to say the least, an emotionally fraught topic. Though many people have experienced the loss of a loved one to suicide, the subject is rarely openly discussed. And that, says Well+Good Council member and practicing psychiatrist Drew Ramsey, MD, is exactly why we *need* to talk about it. Here's how to start the conversation.
I walked off the small stage after being introduced as a new member of the Well+Good Wellness Council. I was feeling the excitement in the room: the good vibes, the handshakes and hugs, and the openness and encouragement to talk more about mental health. At that moment, I met a woman’s gaze and we locked eyes. She had something to tell me. I asked her what I should write about for Well+Good.
“Suicide,” she said.
So C, this post is for you. And for everyone else who is sitting with the weight of a being a suicide survivor, having suicidal thoughts, or loving someone who is suicidal, this post is for you, too.
Why it's hard to discuss
The stats are grim; the causes are many. With more than 40,000 suicide victims a year, you likely know something first-hand about suicide and its aftermath. Certainly suicide is a classic puzzle of mental health: one part biology, one part circumstance, and often one part mystery.
Suicide is a word like cancer. We don’t like to say it, and talking about it makes us uncomfortable.
Suicide is a word like cancer. We don’t like to say it, and talking about it makes us uncomfortable. I’ve taught psychiatry residents and medical students to assess someone’s risk for suicide for the past 15 years and there is an inevitable awkwardness around the subject. After all, if you haven’t been suicidal, feeling suicidal makes no sense. Things will get better, right? And people also feel that somehow their questions will make things worse—that specifically asking if someone has a plan to kill themselves will trigger them to start planning. Remember that silence, not struggling with a hard conversation, is the enemy.
Know the causes of suicide
Feeling suicidal can range from passive thoughts (say, wanting to check out of this crazy life for a while, or to just go to sleep) to very active thoughts of taking one’s life. Mental health conditions like depression and substance abuse are familiar causes, but having any health condition can increase the risk. Ten percent of individuals with schizophrenia die by suicide. Psychiatric disorders are present in at least 90 percent of suicide victims, but untreated in more than 80 percent of these at the time of death. Having diabetes or cancer increases the risk, too.
In some mental health conditions like borderline personality disorder, suicidal thoughts and gestures are very common. And others, like substance use, include behavior that is so self-destructive, it may not sound like suicide—but it is.
Think like a shrink
Being a psychiatrist is a unique job for many reasons. I ask every patient I meet if they have ever had thoughts of killing themselves. I try not to sound fake or scripted, just curious. I might say something like, “A lot of time when people are this down, they having thoughts of not being around or harming themselves. Have you had these kinds of thoughts?”
Fishing for suicidal symptoms is a lot like fishing. Don’t make a lot of noise and movement. Be still and open to what comes to you. As with fishing, don’t give up. If you are worried someone you love is suicidal, keep casting—be gentle and don't pester, but don't give up. Your instincts are probably right. My number one asset as a clinician is my intuition. When I am worried, I pay close attention. Psychiatrists are trained to assess suicidal thoughts in regards to a person’s intent, plan, and feasibility.
Inquire because you care
People get uncomfortable asking about suicide. I try to set up the question by building in context. First, I inquire generally about how someone is feeling and other symptoms. For example, if a patient is depressed, I’ll cover sleep, mood, and irritability. Mostly though, I am hoping to hear about someone’s inner experience. Second, I frame my question with those symptoms to minimize (and hopefully remove) fear and anxiety. People are frightened to talk about suicide because they think it will trigger a call to 911 or a trip to the ER. I might say something like, “You seem really down, and not sleeping is awful. A lot of people have darker thoughts, like not wanting to be around anymore. What about you?"
You have the ability to notice things, to show care and concern, and to connect them to professional help.
I hope that deepens the conversation, because I want to ask a harder question. Researchers John Mann, MD and Maria Oquendo, MD, developed the Columbia-Suicide Severity Rating Scale, which starts with two questions most effectively screen for suicide: “Have you wished you were dead or wished you could go to sleep and not wake up?” and “Have you actually had any thoughts of killing yourself?”
Feeling like checking out in the midst of stress or wishing it was all over is different than visualizing killing yourself. As a psychiatrist, I have many tools to help me assess a person’s risk. It’s not your job to know how to do that. But unfortunately, many folks struggling with depression and suicidal thinking are not in treatment with a mental health professional. You are there with them in their everyday lives. You have the ability to notice things, to show care and concern, and to connect them to professional help.
Consider asking questions
Other guideposts I use in risk assessment are family history, past attempts, and demographics. Inquire about a family history of suicide attempts or completion as well as recent suicides in the person’s life. For instance, you could ask, “Do you know anyone who has died by suicide or tried?” or "Has anyone in your family attempted suicide?” The best predictor of future attempts is past attempts, but this always concerns me. Many suicides are completed on first attempts. Finally, the demographics are surprising. Even though more women attempt suicide than men, I’m more worried about suicidal thoughts in older males—after all, 76 percent of suicidal completions in the United States were white men.
Identify the classic signs
Loss of pleasure in previously enjoyable activities. Giving away possessions. Joking about suicide or “when I am gone.” Talking about how everyone would be better off without them. Changes in sleep. Increased drug or alcohol use. These are the classic signs.
And pay special attention to a new interest in acquiring a gun or requests to borrow a firearm. Firearms account for 51 percent of all suicides in this country. In a survey of 36 wealthy nations, the United States was unique in having the highest overall firearm mortality rate and the highest proportion of suicides by firearms. Guns are used for more suicides in the United States each year than for homicides.
By that, I mean phrases like this: You have so much to live for. It will get better. It’s not logical. Come on, you have so much.
Getting a suicide assessment right is my job. Yours is to open up a conversation and reach out to someone you know who is struggling. And know this: You can be helpful and supportive, but ultimately, you can't control someone else's actions. I have accepted the inability to control my situation. A patient of mine who hung himself had never had suicidal thoughts. Another looked his mother in the eye after she asked all the right questions and denied any troubles. She found him dead the next morning. After a physician I treat emerged from a very severe depression, he let me know he had been timing the express train at his local stop, creeping closer and closer to the edge of the platform. Asking, talking, and clinical treatment won’t prevent every suicide—but not talking about it surely won’t.
In an emergency, ask your loved one, "Do you feel unsafe in any way?" Remember that emergency rooms exist for a reason and that intense suicidal feelings are a medical emergency. “I’m worried about your health, let’s talk to a doctor and get some advice.” Get facts and learn from trusted sources such as the American Psychiatric Association, the American Society for Suicide Prevention, and The Jed Foundation.
The 24/7 National Suicide Prevention Lifeline: 1-800-273-TALK (en Español: 1-888-628-9454) is a great resource. Don't worry about how you'll come across. The conversation you start just might save a life.
Originally published on February 20, 2018. Updated on June 8, 2018.
As a psychiatrist and farmer, Dr. Drew Ramsey specializes in exploring the connection between food and brain health (i.e. how eating a nutrient-rich diet can balance moods, sharpen brain function, and improve mental health). When he’s not out in his fields growing his beloved brassica—you can read all about his love affair with the superfood in his book 50 Shades of Kale—or treating patients through his private practice in New York City, Dr. Ramsey is an assistant clinical professor of psychiatry at Columbia University College of Physicians and Surgeons.
What should Drew write about next? Send your questions and suggestions to firstname.lastname@example.org.
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