The death of a child is devastating enough, but how do parents and loved ones cope when a child commits suicide?

Most of us can't even imagine what it would be like to lose a child in an accident, or assault or as a result of an illness. Can you imagine then how much more difficult, emotionally, it might be for a parent to lose a child as a result of suicide? Though suicides amongst children and teens are not very common, tragically they do happen.

Parental Guilt When A Child Commits Suicide

When a child dies by suicide, it brings about not only the usual emotions found in the grieving process, but, in addition, often brings about a great sense of guilt for parents, family members and close friends. "Could I have done more?" "Might I have prevented the suicide if only I had..."

There is often frustration between the two parents with regard to what could have or should have been done that might have prevented the depression or behavior that led to the suicide. Anger is a normal part of the grief reaction, and in the case of a suicide of a child, that anger can lead to fights between the parents or between parents and friends of the child about what "could have or should have" been done to prevent the suicide.

Impact of Child Suicide

When I was in training, I was taught that parents who lose a child, especially to suicide, were more likely to divorce than other couples. Fortunately, a review of the research literature shows that this is not the case. While it is certainly true that the death of a child (especially from suicide) can strain a marital relationship, there is no evidence that the suicide is more likely to result in separation or divorce than other causes of marital discord. In some cases, the loss and bereavement may, in fact, strengthen a relationship although it often takes years before the effects of the death of a child result in stabilization of a relationship.

Coping with the Suicide of a Child

Most of the experts agree that the best thing to do following the loss of a child, especially to suicide, is to find a support group that understands and can help the bereaved parents cope with the feelings that they may have and yet not understand very well. This may be accomplished through finding a formal support group or getting counseling from a mental health professional, clergyman, or both.

Some people are chronically suicidal. What causes that and is psychotherapy effective in treating the chronically suicidal person?

The benefits of psychotherapy in treating the chronically suicidal patient, as well as strategies that can help the potential suicide patient imagine and reflect others' reactions to this most final of acts, was the subject of a conference by Glen O. Gabbard, M.D., at the 11th Annual U.S. Psychiatric & Mental Health Congress. Gabbard is the Bessie Callaway Distinguished Professor of Psychoanalysis and Education at the Karl Menninger School of Psychiatry and Mental Health Sciences.

Based on previous research and his own experiences as a psychotherapist, Gabbard has found that in some patients, especially those diagnosed with borderline personality disorder, the ability to imagine other people's feelings and reactions to their suicide is impaired.

Gabbard said that physicians should enter into their patient's suicidal fantasies instead of avoiding the subject due to clinician discomfort or the usually incorrect assumption that patients will become more suicidal as a result of an open dialogue. In turn, he commented, this will enable patients to understand the consequences of their suicide. Gabbard also recommends that physicians facilitate a detailed elaboration of the borderline patient's fantasies about what happens after the suicide is completed. "This frequently leads to a recognition that the patient is not adequately imagining the reaction of others to his or her [own] suicide," he said.

Development of Mentalization

"Part of the borderline patient's psychopathology is a kind of absorption in a very limited, narrow view of their own suffering, where the subjectivity of others is completely disregarded. They often have a very poor sense of subjectivity regarding other people," Gabbard explained. "To a large extent there is an incapacity to imagine another person's internal role or their own internal role. So they are very much out of touch with inner life."

Mentalization and reflective functions are often used in very similar ways, said Gabbard, and involve the theory of mind, which is the capacity of a person to think of things as motivated by feelings, desires and wishes. In other words, he noted, "you're not just the sum total of your brain chemistry."

"If things go well," Gabbard continued, "mentalization will develop after the age of 3. Before the age of 3, you have what's called psyche equivalence mode, where ideas and perceptions are not found to be representations, but rather accurate replicas of reality. In other words, a little kid will say, 'The way I see things is the way they are.' This child is not representing anything, it's just the way he sees it."

According to Gabbard, after the age of 3, this kind of thinking develops into the pretend mode, where the child's idea or experience is representational rather than a direct reflection of reality. He cited an example of a 5-year-old boy who says to his 7-year-old sister, "Let's play mommy and baby. You'll be the mommy and I'll be the baby." In normal development, the child knows that the 7-year-old sister is not mommy, but a representation of mom. He also knows that he's not baby, but a representation of baby, Gabbard said.

A borderline patient, on the other hand, has great difficulty with mentalizing and reflective powers, Gabbard explained. Just as the child before age 3, they are stuck developmentally, and may comment to their therapist, "You are exactly like my father." In normal development, however, Gabbard noted that "reflective functions contain both self-reflective and interpersonal components. That ideally provides the individual with a well-developed capacity to distinguish inner from outer reality, pretend mode from real mode of functioning, [and] interpersonal mental and emotional processes from interpersonal communications."

According to Gabbard, recent studies show that traumatized children who can maintain mentalization or reflective functions and process it with a neutral adult have a much better chance of coming out of the trauma without serious scarring. "You always see these amazing kids who have been abused pretty thoroughly," he said, "and yet they're fairly healthy because somehow they've been able to appreciate what happened and why."

As a result, Gabbard will often ask a borderline patient, "How did you imagine that I felt when you were suicidal and didn't show up at your session?" Or, "How did you imagine I felt when I was sitting in my office wondering where you were and if you had hurt yourself?" By doing this, he said, patients can start developing fantasies about how other people think.

"If I want to get the child or adult to move from this kind of psychic equivalence mode to a pretend mode, I can't just copy the patient's internal state, I have to offer a reflection about them," said Gabbard. For instance, in his practice, Gabbard observes the patient, then tells them, "this is what I see going on." Thus, he explained, the therapist can gradually help the patient learn that mental experience involves representations that can be played with and ultimately altered.

Clarifying the Picture: A Vignette

Gabbard illustrated this by discussing a former patient he considers one of his most difficult: a 29-year-old chronically suicidal woman who is an incest survivor with borderline personality disorder. "She was difficult," Gabbard explained, "because she would show up [to the session], and then she wouldn't want to talk. She'd only sit there and say, 'I just feel terrible about this.'"

Searching for a breakthrough, Gabbard asked the woman if she could draw what she was thinking. After being presented with a large pad of paper and colored pencils, she promptly drew herself in a cemetery, six feet underground. Gabbard then asked the woman if he could be allowed to draw something into her picture. She agreed, and he drew in the woman's 5-year-old son, standing beside the tombstone.

The patient was obviously upset and asked why he had drawn her son into the picture. "I told her because [without her son] the picture was incomplete," Gabbard said. When the patient accused him of trying to lay a guilt trip on her, he replied that all he was trying to do was get her to think realistically about what would happen if she did kill herself. "If you're going to do this," he told her, "you have to think about the consequences. And, for your 5-year-old son, this is going to be pretty much of a disaster."

Gabbard chose this approach because emerging psychological literature suggests that the capacity to mentalize results in a kind of prophylactic effect against the pathogenicity of problems. "One of the things I was trying to say to this patient by drawing her 5-year-old son into the picture was, 'Let's try to get into your son's head and think what it would be like for him to experience [your suicide].' I was trying to get her to imagine that other people have a separate subjectivity from her own."

According to Gabbard, this helps the patient gradually learn that mental experience involves representations that can be played with and ultimately altered, thereby "re-establishing a developmental process by reflecting what's going on inside the patient's head and what might be happening in other people's heads."

Two months after the session, the patient was released from the hospital and returned to her home state where she began seeing another therapist. About two years later, Gabbard ran into that clinician and asked how his former patient was doing. The therapist said that the woman was doing better and frequently made reference to the session where Gabbard had drawn her son into the picture. "She often gets very angry about this," the therapist told him. "But then, she is still alive."

Gabbard said that in his practice he tries to stress to the borderline patient that they have human connections even when they feel like nobody cares about them. "If you look at the suicidal borderline patient," he said, "almost all of them have a kind of despair, a sense of radical absence of meaning and purpose and the impossibility of human connection because they have so much difficulty in relationships. And yet many of them are more connected than they actually realize."

Unfortunately, Gabbard has seen this most often in inpatient situations where a fellow patient's suicide takes a heavy toll on the other patients. "I remember vividly a group therapy session in a hospital after a patient had killed herself," he said. "While people were sad, I was more impressed with how furious they were. They would say, 'How could she do this to us?' 'How could she leave us with this?' 'Didn't she know that we were connected with her, that we were her friends?' So there was a huge impact on the people left behind."

The Pitfalls of Rescuing

Gabbard noted that there is a drawback in working so closely with the chronically suicidal: Through objective identification, the clinician starts to feel what a patient's family member or significant other might feel if that patient committed suicide. "Sometimes, the clinician's attempt to identify with members of the suicidal patient's family leads to increasingly zealous efforts to stop the patient from committing suicide," he added.

Gabbard cautioned clinicians about their attitudes toward treating these patients. "If you get too overly zealous in trying to rescue the patient, you're starting to create a fantasy that you are an omnipotent, idealized, all-loving parent who's always available, but you're not," he said. "It's bound to lead to resentment if you try to take that role. Plus, you're bound to fail, because you simply can't be available at all times."

There is also a tendency for patients to assign responsibility elsewhere for staying alive. According to Gabbard, Herbert Hendin, M.D., made the point that to allow a borderline patient's tendency to assign others this responsibility is a very lethal feature of suicidal tendencies. The clinician is then haunted by the need to keep this patient alive, he said. This, in turn, may lead to countertransference hate: the clinician may forget appointments, say or do things subtly and so forth. Such behavior may actually lead the patient to suicide.

The therapist can also act as a vehicle for understanding by containing "affects that are not tolerable to the patients," Gabbard said. "Eventually the patient sees that these affects are tolerable and they don't destroy us, so maybe they won't destroy the patient. I don't think we need to worry too much about making brilliant interpretations. I think it's more important to be there, to be durable and authentic and try to contain these feelings and survive them."

In closing, Gabbard noted that 7% to 10% of borderline patients kill themselves and that there are terminal variant patients that do not seem to respond to anything. "We do have terminal illnesses in psychiatry just like we do in every other medical profession, and I think we have to recognize some patients are going to kill themselves despite our best efforts. [We need to] try to avoid taking on all the responsibility of that," Gabbard said. "The patient has to meet us halfway. We can only do so much, and I think accepting our limits is a very important aspect."

Source: Psychiatric Times, July 1999

Further Reading

Fonagy P, Target M (1996), Playing with reality: I. Theory of mind and the normal development of psychic reality. Int J Psychoanal 77(Pt 2):217-233.

Gabbard GO, Wilkinson SM (1994), Management of Countertransference With Borderline Patients. Washington, D.C.: American Psychiatric Press.

Maltsberger JT, Buie DH (1974), Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 30(5):625-633.

Target M, Fonagy P (1996), Playing with reality: II. The development of psychic reality from a theoretical perspective. Int J Psychoanal 77(Pt 3):459-479.

Anorexics More Likely to Have Suicidal Thoughts

A study of Swiss women with eating disorders suggests that those who binge and purge are more likely to have attempted suicide in the past, regardless of whether they have been diagnosed with anorexia nervosa, bulimia nervosa or another type of eating disorder. Women with anorexia, however, are more likely to have suicidal thoughts than those with bulimia or other disorders, say Gabriella Milos, M.D., and colleagues at the University Hospital in Zurich, Switzerland. Their study appears in the journal General Hospital Psychiatry.

The researchers also found that most of the women in the study had other psychiatric disorders besides an eating disorder, including depression, drug or alcohol abuse or fearfulness or anxiety. Almost 84 percent of the patients had at least one other psychiatric problem.

Milos and colleagues say the link between purging and suicidal attempts might be due to a lack of impulse control, which would affect both behaviors.

The higher prevalence of suicidal thoughts among women with anorexia could point to a different phenomenon, they say. Women in the study who reported suicidal thoughts tended to be much younger when their eating disorder appeared and were more fixated on their appearance and fearful of weight gain than those without suicidal thoughts.

Self-Harming Behavior

"Anorexia nervosa patients' starvation is a form of chronic self-harming behavior and continuously maintaining underweight generates considerable distress," Milos says. The two-year study included 288 patients diagnosed with some form of an eating disorder. Twenty-six percent of the women said they had attempted suicide at least once in the past, a rate that is four times higher than in the general female population of Western states, the researchers say. Also, about 26 percent of the patients said they were having current thoughts about suicide.

Milos and colleagues acknowledge that they did not analyze information on any treatment the women were receiving for their eating disorders, which could have affected the rate of suicidal thoughts.

The study was supported by the Swiss National Science Foundation and by the Swiss Federal Department for Education and Science.

What causes some teenagers to consider suicide, taking their own life? Read on to discover the role of depression in teen suicide.

Teen suicide is becoming more common every year in the United States. In fact, only car accidents and homicides (murders) kill more people between the ages of 15 and 24, making suicide the third leading cause of death in teens and overall in youths ages 10 to 19 years old.

Read on to learn more about this serious issue - including what causes a teen to consider taking their own life, what puts a teen at risk for suicide or self-harm, and warning signs that someone might be considering suicide and how they can get help to find other solutions.

Thinking About Suicide

It's common for teens to think about death to some degree. Teens' thinking capabilities have matured in a way that allows them to think more deeply - about their existence in the world, the meaning of life, and other profound questions and ideas. Unlike kids, teens realize that death is permanent. They may begin to consider spiritual or philosophical questions such as what happens after people die. To some, death, and even suicide may seem poetic (consider Romeo and Juliet, for example). To others, death may seem frightening or be a source of worry. For many, death is mysterious and beyond our human experience and understanding.

Thinking about suicide goes beyond normal ideas teens may have about death and life. Wishing to be dead, thinking about suicide, or feeling helpless and hopeless about how to solve life's problems are signs that a teen may be at risk - and in need of help and support. Beyond thoughts of suicide, actually making a plan or carrying out a suicide attempt is even more serious.

What makes some teens begin to think about suicide - and even worse, to plan or do something with the intention of ending their own lives? One of the biggest factors is depression. Suicide attempts are usually made when a person is seriously depressed or upset. A teen who is feeling suicidal may see no other way out of problems, no other escape from emotional pain, or no other way to communicate their desperate unhappiness.

Researchers uncover why many people don't follow through on suicidal thoughts and feelings.

Many people don't act on suicidal thoughts during depressive episodes because of inner strengths, or protective mechanisms that often "kick-in" during times of crisis, according to a study published in the July 2002 issue of the American Journal of Psychiatry.

The investigators studied 84 patients with major depression of whom 45 had attempted suicide. They found that the 39 who had not attempted suicide scored high on the Reasons For Living Inventory, a self-report instrument which measures beliefs that may help a person overcome suicidal behavior. The 45 who had attempted suicide scored high for hopelessness, their own perception of depression, and suicidal thoughts.

Researchers from the New York State Psychiatric Institute, Columbia University, and University of Pittsburgh found that examining survival and coping beliefs, responsibility to family, child-related concerns, fear of suicide, fear of social disapproval, and moral objections to suicide can often offset the perception of hopelessness a patient might have during a depressive episode.

"That perception of adversity or despair -- as opposed to the actual adversity itself -- was an important determinant of suicidal thoughts during depression," said lead researcher Kevin M. Malone, M.D.

"We suggest that Reasons For Living may be clinically useful to assess suicidal patients, and recommend that ways of using the RFL construct within psychotherapy with suicidal patients be explored," said Malone. "Basically, this confirms common sense, but doctors need to look for reasons patients should have hope."

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week.

Or for a crisis center in your area, visit the National Suicide Prevention Lifeline.

Feeling suicidal? Ways to help yourself if you're feeling suicidal or suffering from deep depression.

Here are some ways to help yourself if you're feeling suicidal:

1. Tell your therapist, a friend, a family member, or someone else who can help.

2. Distance yourself from any means of suicide. If you are thinking of taking an overdose, give your medicines to someone who can give them to you one day at a time. Remove any dangerous objects or weapons from your home.

3. Avoid alcohol and other drugs of abuse.

4. Avoid doing things you're likely to fail at or find difficult until you're feeling better. Know what your present limits are and don't try to go beyond them until you feel better. Set realistic goals for yourself and work at them slowly, one step at a time.

5. Make a written schedule for yourself every day and stick to it no matter what. Set priorities for the things that need to be done first. Cross things out on your schedule as you finish them. A written schedule gives you a sense of predictability and control. Crossing out tasks as you complete them gives a feeling of accomplishment.

6. In your daily schedule don't forget to schedule at least two 30-minute periods for activities which in the past have given you some pleasure such as: listening to music, playing a musical instrument, meditating doing relaxation exercises, doing needlework, reading a book or magazine, taking a warm bath, sewing, writing, shopping, playing games, watching your favorite DVD or video, gardening, playing with your pet, participating in a hobby, taking a drive or a walk.

7. Take care of your physical health. Eat a well-balanced diet. Don't skip meals. Get as much sleep as you need, and go out for one or two 30-minute walks each day.

8. Make sure you spend at least 30-minutes a day in the sun. Bright light is good for everyone with depression, not just people with seasonal affective disorder (SAD).

9. You may not feel very social but make yourself talk to other people. Whether you talk about your feelings or about any other topic, reducing your social isolation is likely to be helpful.

Remember that while it may feel as if it will never end, depression is not a permanent condition.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week.

Or for a crisis center in your area, visit the National Suicide Prevention Lifeline.

The causes of elderly suicide are treatable and suicide is preventable. Risk Factors for elderly suicide and how to help suicidal seniors.

How You Can Help Prevent A Senior From Committing Suicide

For most older people, their life is a time of fulfillment, satisfaction with life's accomplishments. For some older adults, however, later life is a time of physical pain, psychological distress, and dissatisfaction with the present, and, perhaps, past aspects of life. They feel hopeless about making changes to improve their lives. Suicide is one possible outcome. However, the causes of elderly suicide are treatable and suicide is preventable. Each year more than 6,300 older adults take their own lives, which means nearly 18 older Americans kill themselves each day

Older adults have the highest suicide rate -- more than 50% higher than young people or the nation as a whole. Suicide is rarely caused by any single event or reason. Rather, it results from many factors working in combination which produce feelings of hopelessness and depression. Since suicide for the older person is not an impulsive act, you have a window of opportunity to help the older person get help. YOU can help prevent a suicide.

Risk Factors for Elderly Suicide

Suicide can happen in any family. However, life events commonly associated with elderly suicide are:

• the death of a loved one
• physical illness
• uncontrollable pain
• fear of dying a prolonged death that damages family members emotionally and economically
• social isolation and loneliness
• and major changes in social roles, such as retirement.

Among the elderly, white men are the most likely to die by suicide, especially if they are socially isolated or live alone. The widowed, divorced, and recently bereaved are at high risk. Others at high risk include depressed individuals and those who abuse alcohol or drugs.

Clues to Look for in Suicidal Older Men and Women

There are common clues to possible suicidal thoughts and actions in the elderly that must be taken seriously. Knowing and acting on these clues may provide you the opportunity to save a life. In addition to identifying risk factors, look for clues in someone's words and/or actions.

It is important to remember that any of these signs alone is not indicative of a suicidal person. But several signs together may be very important. The signs are even more significant if there is a history of suicide attempts.

A suicidal person may show signs of depression, such as:

• changes in eating or sleeping habits
• unexplained fatigue or apathy
• trouble concentrating or being indecisive
• crying for no apparent reason
• inability to feel good about oneself or unable to express joy
• behavior changes or are just "not themselves"
• withdrawal from family, friends or social activities
• loss of interest in hobbies, work, etc.
• loss of interest in personal appearance

A suicidal person also may:

• talk about or seem preoccupied with death
• give away prized possessions
• take unnecessary risks
• have had a recent loss or expect one
• increase their use of alcohol, drugs or other medications
• fail to take prescribed medicines or follow required diets
• acquire a weapon.

Immediate Action Is Needed If The Person Is Threatening Or Talking About Suicide If you have contact with older adults, look for these clues to a potentially suicidal person. Your observing, caring about, and talking with a suicidal older adult can make the difference between life and death.

You See the Warning Signs of Suicide. What Now?

Some DOs and DON'Ts include:

1. DO learn the clues to a potential suicide and take them seriously.

2. DO ask directly if he or she is thinking about suicide. Don't be afraid to ask. It will not cause someone to be suicidal or commit suicide. You will usually get an honest answer. But don't act shocked, since this will put distance between you. (Some people may deny feeling suicidal but may still be very depressed and need help. You can encourage them to seek professional help for their depression. It's treatable.)

3. DO get involved. Become available. Show interest and support.

4. DON'T taunt or dare him or her to do it. This "common remedy" could have fatal results.

5. DO be non-judgmental. Don't debate whether suicide is right or wrong, or feelings are good or bad. Don't lecture on the value of life.

6. DON'T be sworn to secrecy. Seek support. Get help from persons or agencies that specialize in crisis intervention and suicide prevention. Also seek the help of the older person's social support network: his or her family, friends, physician, clergy, etc.

7. DO offer hope that alternatives are available but do not offer glib reassurance. It may make the person feel as if you don't understand.

8. DO take action. Remove easy methods they might use to kill themselves. Seek help.

Finding Help for the Suicidal Person

There are resources available to help suicidal seniors. If you think that the person might harm him/herself or you observe clues of a possible suicide, immediately contact a professional to help. A community mental health agency, a private therapist, a family physician, a psychiatrist or medical emergency room, or a suicide/crisis center are resources listed in the yellow pages of your phone book.

Suicide is preventable at any age. Most suicidal persons do not want to die so much as they want to be rid of their emotional or physical pain. They need help. Depression is not a normal part of aging. The treatment for depression has a very high success rate. We can prevent the premature, unnecessary self-inflicted deaths of our seniors. Suicide causes society the loss of talent, skills, and knowledge as well as the personal loss of a loved one to the surviving family member. This is no less true when the person is an older adult.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week.

Or for a crisis center in your area, visit the National Suicide Prevention Lifeline.

Resources

American Association of Suicidology (202) 237-2280

American Association of Retired Persons 1-800-424-3410

Source: John McIntosh, Ph.D. Professor of Psychology, Indiana University-South Bend

Detailed statistics on suicide in the U.S. Covering adult and youth suicide, suicide among seniors, methods of suicide and more.

Studies indicate that the best way to prevent suicide is through the early recognition and treatment of depression and other psychiatric illnesses.

• Over 32,000 people in the United States kill themselves every year.
• Suicide is the 11th leading cause of death in the United States.
• Suicide is the fourth leading cause of death for adults between the ages of 18 and 65 years in the U.S., with approximately 26,500 suicides.
• A person dies by suicide about every 16 minutes in the U.S. An attempt is made once a minute.
• Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.
• There are more than four male suicides for every female suicide. However, at least twice as many females as males attempt suicide.
• Every day, approximately 80 Americans take their own life, and 1500 attempt. There are an estimated eight to twenty-five attempted suicides to one completion.

Youth Suicide

• Suicide is the 5th leading cause of death among all those 5 to 14 years of age.
• Suicide is the 3rd leading cause of death among all those 15 to 24 years of age.
• The suicide rate for white males age 15 to 24 has tripled since 1950, while for white females, it has more than doubled. Among persons age 10 to 14 years, the rate has increased by 100%. Since the mid-1990s, the youth suicide rate has been steadily decreasing.
• Among young people aged 10-14 years, the rate has doubled in the last two decades.
• Between 1980-1996, the suicide rate for African-American males aged 15-19 has also doubled.
• Risk factors for suicide among the young include suicidal thoughts, psychiatric disorders (such as depression, impulsive aggressive behavior, bipolar disorder, certain anxiety disorders), drug and/or alcohol abuse and previous suicide attempts, with the risk increased if there is also access to firearms and situational stress.

Suicide Among Seniors

• The suicide rates for men rise with age, most significantly after age 65.
• The rate of suicide in men 65+ is seven times that of females who are 65+.
• The suicide rates for women peak between the ages of 45-54 years old, and again after age 75.
• About 60 percent of elderly patients who take their own lives see their primary care physician within a few months of their death.
• 6-9 percent of older Americans who are in a primary care setting suffer from major depression.
• More than 30 percent of patients suffering from major depression report suicidal ideation.
• Risk factors for suicide among the elderly include: a previous attempt, the presence of a mental illness, the presence of a physical illness, social isolation (some studies have shown this is especially so in older males who are recently widowed) and access to means, such as the availability of firearms in the home.

Depression and Suicide

• Over 60 percent of all people who die by suicide suffer from major depression. If one includes alcoholics who are depressed, this figure rises to over 75 percent. Depression affects nearly 10 percent of Americans ages 18 and over in a given year, or more than 19 million people.
• More Americans suffer from depression than coronary heart disease (12 million), cancer (10 million) and HIV/AIDS (1 million).
• About 15 percent of the population will suffer from clinical depression at some time during their lifetime. Thirty percent of all clinically depressed patients attempt suicide; half of them ultimately die by suicide.
• Depression is among the most treatable of psychiatric illnesses. Between 80 percent and 90 percent of people with depression respond positively to treatment, and almost all patients gain some relief from their symptoms. But first, depression has to be recognized.

Alcoholism and Suicide

• Ninety-six percent of alcoholics who die by suicide continue their substance abuse up to the end of their lives.
• Alcoholism is a factor in about 30 percent of all completed suicides.
• Approximately 7 percent of those with alcohol dependence will die by suicide.

Guns and Suicide

• Although most gun owners reportedly keep a firearm in their home for "protection" or "self-defense," 83 percent of gun-related deaths in these homes are the result of a suicide, often by someone other than the gun owner.
• Firearms are used in more suicides than homicides.
• Death by firearms is the fastest growing method of suicide.
• Firearms account for 52 percent of all suicides.

Above figures from the National Center for Health Statistics for the year 2005.
Source: American Foundation for Suicide Prevention

Taking a suicidal person seriously is the first step to help prevent suicide.

If someone threatens or makes statements referring to suicide, take them seriously. Many people have taken their lives when people thought their statements about suicide were "manipulative" or the person was being "melodramatic".

Many people have died "accidentally". They may take some medication, for example, just to get others to hear them and feel they will be discovered and saved. Instead of calling attention to their needs, they in fact, died.

If the person is telling you either in person or over the phone that they are going to kill themselves, you call 911 right now. Law enforcement will come to the person's home and take them to be evaluated by a mental health person. Even if you feel in your heart, that they will not take their life, you go by what they are telling you. Don't wait to get over to their home to call 911. You call 911 right now from where ever you are.

If the suicidal person forbids you to call, is angry about it or upset, you call anyway. If you need to go to a neighbor's home to call, do it. If it's in the middle of the night, wake up the neighbor and make that call.

If the person is calling from an unknown location and discusses suicide, try to find out where they are. You cannot send someone to them if you do not know where to find them.

What if that person has you in confidence and makes you swear that you will not tell anyone how they are feeling? Do you keep that confidence? No. Would you be a lousy friend, mother, etc., if you broke that confidence? No. Suicidal discussion automatically ends confidentiality.

A person in crisis may not be aware that they are in need of help or be able to seek it on their own. They may also need to be reminded that effective treatment for depression is available, and that many people can very quickly begin to experience relief from depressive symptoms.

Ask these questions first:

1. Plan - do they have one?
2. Lethality - is it lethal? Can they die?
3. Availability - do they have the means to carry it out?
4. Illness - do they have a mental or physical illness?
5. Depression - chronic or specific incident(s)?

What if the person does not "qualify" for the above statements? Do you not take them seriously? Yes, always take people seriously when suicide is discussed. If they truly want to die, they may not tell you the truth about their plan.

All it takes is for someone to say, "I am going to kill myself" to call 911. When law enforcement comes, they will assess the person. They will talk to the person. There are times where the person is not "taken" by law enforcement, but I do believe it is helpful to have law enforcement there to talk with them.

After you have taken emergency measures as described above, or the person is not in immediate risk, what do you say to them?

Do not:

• Judge them
• Show anger towards them
• Provoke guilt
• Discount their feelings
• Tell them to "snap out of it"

Do:

• Acknowledge and accept their feelings even if they appear distorted - "You sound like you are feeling abandoned...", "That must have hurt you terribly...", "How does that make you feel...?", "Are you feeling like there is no hope?"
• Be an active listener - repeat some of their statements back to them to let them know you are listening. For example, "So what you are saying is....", "I'm hearing you saying you hate yourself...", "I hear you saying you want to die...", etc.
• Try to give them hope and remind them what they are feeling is temporary, without provoking guilt. "I know you feel you cannot go on, but things will get better", "What you are feeling is temporary", "I believe in you and that you will get better", "There is a light at the end of the tunnel - it's okay if you don't see it now".
• Be there for them. If they are not there with you, go to them or have them come to you. It is better if you go to them, in case they don't show up where you are.
• Show love and encouragement. Hold them, hug them, touch them. Allow them to show their feelings. Allow them to cry, to show anger, etc. Let them know you hear them and are there for them. Let them know it is okay to feel what they feel, even if it is distorted. Let them know you accept them right where they are now. If you love them, tell them.
• Pamper them. Feed them if they are hungry. Let them shower if you feel that will help them. Rent a movie if they feel like it. Turn on their favorite music if it makes them feel better.
• Help them get some help. If phone calls are needed for counseling, drug recovery, doctor appointments, etc., encourage them to make these calls. It is better if they call, but it's okay if you need to make these calls if their level of functioning is low. If they have a counselor, psychologist, psychiatrist, etc., this is a good time to call them if the person is still at risk. If it's evening and the person is not at risk, calls should be made the next day to these people, informing them of the person's suicidal ideation. The mental health professional may make an adjustment to the person's medications, admit them to the hospital, etc.
• If you are the person's home, remove any item/items the person may use to hurt themselves with. Grab their medication or weapon. Make these items inaccessible to the suicidal person until they are safe.
• Is there a child or children of the suicidal person witnessing their parent's crisis? Try to get the child out of there (after the person is safe) and into a friend or relative's home. This situation is extremely traumatic for children. Many times we think they are asleep but they are fully aware of the situation at hand.

A list of reasons why you may feel like dying plus how depression creates suicidal thoughts.

Because...

• Because you have an illness that makes you want to kill yourself
• Because you are not just depressed - you have depression
• Because - just like with any other illness - you must get treatment to get rid of the symptoms and the pain
• Because you can treat depression, even cure it
• Because your life has value and can be saved

Why Can't You Believe It?
Because you have a biological brain disorder...

• that under-produces positive emotion
• that over-produces negative emotion
• poisons your thoughts
• and makes you believe that you must die

If you hurt your leg...

• You can sit and look down
• And see a gash in your leg, down there, as a part of your body, and say
• "Oh, ouch, my leg is hurt, but it - this exterior part of my body will get better"
• You are experiencing the pain in your leg, in a part of your body
• And you are willing to suffer the pain, treat the wound, and expect it to heal

The trouble with depression is that...

• The very disorder and pain is in your reasoning, happiness, and will to live mechanisms - in your heart, in your soul
• The entire experience of self and life continuum is affected
• There is no space in your head and heart for objectivity
• It's as though the pain IS you
• Lost in and disabled by the pain, often we are not able to objectively seek the proper treatment as we would for our injured leg, or to persevere when treatment fails to help

If you had any other illness, disease, or injury...

• you would accept the pain
• apply a treatment
• fight for life
• wait for healing
• and expect to get well

Just like with any illness...

• You may have to suffer for a while longer before you get better

Normally, people can stand a certain amount of very bad and even excruciating pain...

• whether from a physical injury, or an internal disease like cancer
• from a life circumstance - loss of a job or home
• or from losing a loved one through death or divorce

But after a while, pain wears on us...

• Often, normal people in constant pain for an extended length of time will begin to think of suicide even though they never thought of it before

And that's just about where depression starts. We are already there in state of physiological injury
Our malfunctioning biochemistry creates a constantly descending altered mental and physical state...

• We are immersed in a biochemistry of sadness, hopelessness, worthlessness, pain and sorrow
• Our hearts are physically aching as though something horrible and terrible has happened to us
• Our negative emotions are on high and our positive, balancing emotions are very low or absent
• We may be physically incapable of creating positive thought

If you are suicidal, your brain is not thinking straight!
Just like when we are upset and angry with someone...

• Reasoning power is impaired
• We feel, think, say, and do things we often "don't mean" and are sorry for later
• In depression, we are biochemically upset all the time
• It's as if a malfunctioning part of your brain is fooling you!

Don't believe what you are thinking and feeling!
The pain speaks to us...

• The pain is making you think and believe that you have to die
• You feel that your life is over and that depression is a terminal illness
• But you don't have to die 

Is depression a terminal illness?
Yes and no...

• Depression, just like cancer:
  • If you don't discover it,
  • If you don't treat it,
  • It will get worse and maybe kill you
• With Depression, the longer you go untreated, the more likely a suicide attempt could be

But is depression treatable?
Yes, highly treatable...

• And new information and treatment options are coming out all the time
• Staying alive and not trying to kill yourself until your treatment works is what matters

Remember - while the biological core of your emotions and sanity are under attack...

• Depression is a physical illness
• And it has physical, biochemical treatments
• A physical, biological illness is not a character flaw or personal weakness
• Somewhere in the darkness of your terrible suffering, can you know that this is only a small and temporary space in a long life and better future to come?
• If you die, you will never know the renewed and wonderful life you could have lived after your depression was over

The life force inside you wants you to live
It holds you back from attempting suicide...

• It causes painful conflict when suicidal thoughts compel you
• Hold onto that something; it does not want you to die
• If suicide were the right thing to do, why would it be so painful to contemplate? Why so difficult to do it?
• The pain says STOP - turn around - go back to life - try to make it work - try to make it right
• Your life force wants you to go on, find treatment, and make a meaningful life for yourself and those you love or will love

How do we make life meaningful?

• By correcting, changing, improving our faulty brain chemistry
• Depression is a treatable illness
• And you can stop the hurting if you reach for the help you need.