There Are Always Signs

From “Rethinking Suicide: Why Prevention Fails, and How We Can Do Better” - Craig J. Bryan

While living in Utah, for instance, I learned that around one third of suicides that were precipitated by an argument occurred during the argument and involved a firearm. “It just happened,” a patient once told me when I asked him to share the story of his own close brush with death under very similar circumstances. He and his wife were having a heated argument, he explained, and “I just wanted it to stop,” so he grabbed his loaded handgun and held it to his head. Thankfully, he stopped himself before pulling the trigger. When I asked him what “it” was that he wanted to stop, he described intense emotional distress: “I just felt completely overwhelmed in that moment.” 

The unexpected nature of many suicide deaths stands in sharp contrast to the suicide prevention community’s assertion that suicidal behaviors are preceded by warning signs or indicators that signal the behavior’s emergence.

For every person who talked about wanting to die or killing themselves and then died by suicide soon thereafter, there were 17 people who talked about wanting to die or killing themselves who then died soon thereafter of a cause other than suicide.

The majority of suicide decedents may therefore show one or more warning signs for suicide but very few individuals who show these warning signs will actually die by suicide.

In other words, 99.97% of those who said they were having no thoughts of death or self-harm and 99.7% of those who said they were having thoughts of death or self-harm nearly every day were still alive one year later.

Thoughts about suicide or wanting to die should be taken seriously because they reflect being in a vulnerable state, but they do not necessarily lead to suicide.

99.6% of those who say they are having no thoughts of death or self-harm as compared to 96% of those who say they are having these thoughts nearly every day did not make a suicide attempt in the year after they reported having thoughts about death or self.

Although more than half of those who attempt suicide or die by suicide previously reported thoughts about death or self-harm, very few individuals who experience thoughts of death or self-harm will attempt suicide or die by suicide.

Approximately 1 in 7,692 individuals die by suicide and 1 in 303 individuals attempt suicide in the United States each year. If someone reports suicidal thoughts, the likelihood of dying by suicide in a given year increases to approximately 1 in 6,250, and the likelihood of attempting suicide in a given year increases to 1 in 204. Knowing that someone is thinking about suicide is therefore better than not knowing, but not by much.

What this all reveals is a key challenge for suicide prevention: any given warning sign for suicide will be wrong far more often than it will be right.

A significant percentage, therefore, of individuals who attempt or die by suicide deny having any suicidal thoughts at all.