Suicide is death caused by self-directed injurious behavior with intent to die. A suicide attempt is a nonfatal self-directed act with intent to die. Suicidal ideation ranges from passive wishes to be dead to active thoughts with a plan. Nonsuicidal self-injury (e.g., cutting to relieve emotional pain) lacks intent to die but still raises future suicide risk.

Suicide results from interacting factors: mental disorders (depression, bipolar disorder, schizophrenia, substance use, borderline personality disorder, PTSD), acute stressors, hopelessness, impulsivity, and access to lethal means. Most people who die by suicide had contact with a health professional in the preceding year, so every nurse has a role in detection.

Risk factors

• Previous suicide attempt — the strongest single predictor
• Mental disorders, especially depression and substance use; hopelessness
• Chronic pain or serious illness; recent diagnosis
• Access to lethal means (firearms, stockpiled medications, pesticides)
• Male sex (higher death rate; females attempt more often), older men, adolescents and young adults
• Social isolation, living alone, recent loss (relationship, job, finances), legal problems
• Family history of suicide; childhood abuse; exposure to another person's suicide
• Stigma or discrimination (e.g., sexual and gender minority youth), veterans
• Periods of transition: the weeks after psychiatric discharge; early antidepressant treatment as energy returns before mood improves

Protective factors: connectedness to family and community, reasons for living (children, faith), access to care, problem-solving skills, restricted access to means.

Common myths

• "Asking about suicide gives people the idea." — False; asking directly is safe and often relieves the person.
• "People who talk about suicide won't do it." — False; most give warning signs.
• "A sudden improvement means the danger is over." — False; sudden calm may reflect a decision to die.

Warning signs

• Talking or writing about death, wanting to die, being a burden
• Researching methods, obtaining a weapon or pills
• Giving away possessions, saying goodbye, writing a will or note
• Withdrawal, increased substance use, reckless behavior
• Extreme mood swings; sudden calm or cheerfulness after deep depression
• Hopelessness, feeling trapped, unbearable pain

Direct assessment — ask clearly

1. Ideation: "Are you thinking about killing yourself?"
2. Plan and specificity: "How would you do it?" / "What method have you thought about?"
3. Means and access: "Do you have access to a gun or to pills?"
4. Intent and timing: "Do you intend to act on these thoughts? When?"
5. Lethality of the method and chance of rescue
6. History: past attempts, their lethality and circumstances
7. Protective factors and supports

Immediate risk is highest when there is current ideation with a specific, lethal plan, available means, intent, and few supports. Past diagnosis, genetics, and social factors add to risk but are secondary to the current plan in judging imminence.

SAD PERSONS-type scores are not reliable alone for predicting suicide; use structured screening plus clinical assessment.

• After a suicide attempt: medical stabilization first — airway, breathing, circulation, treatment of overdose (e.g., acetylcysteine for acetaminophen overdose, given as soon as indicated) or injuries; then psychiatric evaluation
• Hospitalization for high imminent risk; voluntary if possible, involuntary if criteria are met (Topic 15)
• Treat the underlying disorder
  • Antidepressants: benefit outweighs risk, but the boxed warning for increased suicidality under age 25 requires close monitoring early in treatment; prescribe limited quantities to high-risk clients (TCAs are lethal in overdose — see Topic 9)
  • Lithium reduces suicide in mood disorders (narrow therapeutic index; toxicity in overdose — levels, kidney and thyroid monitoring)
  • Clozapine reduces suicidal behavior in schizophrenia (severe neutropenia risk — ANC monitoring)
  • Esketamine for depression with acute suicidal ideation (REMS, 2-hour monitoring, dissociation, BP rise); ECT for severe, high-risk depression
• Psychotherapies that reduce suicidal behavior: CBT for suicide prevention, DBT (recurrent self-harm, borderline personality disorder), brief contact interventions
• Safety planning intervention (Stanley–Brown) with follow-up contact
• Caring contacts — brief follow-up messages, calls, or letters after discharge reduce suicidal behavior

Listed in priority order.

1. Immediate safety
   • After an attempt: treat physical injury first
   • Continuous observation (one-to-one, within arm's length for high risk) as ordered; never leave a high-risk client alone, including in the bathroom
   • Remove dangerous items: belts, shoelaces, cords, glass, razors, plastic bags, medications; search belongings per policy; check trays after meals
   • Ligature-resistant environment; observe closely at shift changes, nights, and weekends when staffing and supervision change
2. Ask directly and document the client's own words
3. Build a therapeutic relationship — calm, nonjudgmental, empathic; do not lecture about the "wrongness" of suicide or demand promises
4. Do not rely on "no-suicide contracts" — they do not prevent suicide and may give false reassurance
5. Collaborative safety plan (written, in the client's words):
   1. Personal warning signs (thoughts, moods, situations)
   2. Internal coping strategies (distraction, relaxation)
   3. People and social settings that provide distraction
   4. People to ask for help
   5. Professionals and crisis services (988 in the US; NCMH hotline in the Philippines)
   6. Making the environment safe — lethal means
6. Lethal means counseling — work with client and family to remove or lock up firearms (store off-site if possible), keep only small quantities of medication, secure pesticides and sharp objects
7. Monitor treatment response — watch for increased energy before mood improves, akathisia, and sudden calm
8. Discharge and transitions — crisis contacts and a concrete plan, a follow-up appointment within days, caring contacts; the weeks after discharge carry the highest risk
9. Community follow-up — frequent contact, medication adherence and side-effect monitoring, coordination of services (enhanced case management)

Crisis-line principles: keep the person engaged, stay connected, express empathy ("I'm here with you"), and assess imminent danger; involve emergency services when a person is in immediate danger.

Postvention (after a suicide): support family, friends, other clients, and staff. Suicide loss often brings guilt, anger, shame, and stigma. Normalize these feelings, provide a nonjudgmental space, and screen survivors for depression and suicidal thoughts. Grief that remains intense and disabling beyond 12 months in adults (6 months in children) may meet criteria for prolonged grief disorder.

• Suicidal thoughts are a symptom of treatable illness; help is available at any hour
• Know your warning signs and follow your safety plan
• Keep crisis numbers in your phone; 988 (US) by call, text, or chat
• Family: take all statements seriously, remove or lock firearms and medications, do not leave the person alone in a crisis, call emergency services if danger is immediate
• Antidepressants take weeks to work; report worsening thoughts immediately and never stop medications abruptly
• Avoid alcohol and drugs, which increase impulsivity

• Previous attempt = strongest risk factor; hopelessness is a major warning sign
• Ask directly: "Are you thinking of killing yourself?" — it does not plant the idea
• Imminent risk: specific plan + lethal method + access + intent; ask "What method?" to assess specificity
• After an attempt: medical stabilization first, then safety and observation
• High-risk client: one-to-one observation, remove dangerous items, never alone
• Safety plan starts with personal warning signs and ends with lethal means safety; no-suicide contracts are not effective
• Means restriction (firearms, medications, pesticides) is a proven population strategy; safe media reporting avoids describing methods
• Primary prevention = universal education and help-seeking promotion; secondary = screening and crisis response; tertiary = follow-up after attempts and postvention
• Highest-risk periods: early antidepressant treatment (energy returns) and the weeks after discharge
• Discharge teaching must include crisis contacts and a coping plan
• Suicide loss survivors: normalize guilt and anger; screen for prolonged grief disorder
• Lithium (mood disorders) and clozapine (schizophrenia) reduce suicide risk