The Fundamental Unpredictability of Suicide

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Recently a friend said, “My partner is threatening suicide. How can I know if he’s serious, manipulating me, or crying for help?” I responded that even seasoned mental health professionals want to know the answer.

I didn’t learn of my grandfather’s suicide until 20 years after it happened, even though we lived with him when he died. For many years, our family wondered, “How could we have predicted this to have gotten him some help?”

In over 50 years of practicing psychiatry, every patient who has died by suicide has surprised me. After each death, I asked myself, “Should I have known? Could I have prevented this?” These are the same questions their surviving loved ones ask me as they deal with the grief that is complicated by feelings of guilt.

Suicide is rising in the United States, with a 33 percent increase since 1999. The greatest increase has been in those over the age of 45. Of those who died, over 50 percent did not have an identified mental health condition. But a retrospective review of those suicides found that 90 percent of those who died had a mental illness, often associated with alcohol or drug abuse.¹

How good is anyone at predicting anyone who will attempt or complete suicide? Determining suicide risk is complex.

What causes someone to consider suicide?

I believe when someone dies by suicide, that person feels hopeless and helpless. They believed nothing would ever change, and no one could help. They often don’t reach out to anyone because they believe it wouldn’t matter if they did. They think, "Why would I reach out; it won't matter if I do."

For some, this represents a life-long struggle with those feelings. For many others, a volcano of those feelings erupts suddenly.

The explanation can be divided into long-term or imminent causes.

Long-term causes include:

• Chronic mental illness
• Genetics, likely with many genetic variants
• Personality type, especially impulsive and aggressive
• Early trauma

Imminent causes include:

• Mental illness–Acute onset
• Physical illness
• Crisis, e.g., shame and humiliation
• Alcohol and substance use
• Availability of firearms²
• Exposure to the suicide of a loved one
• Predicament–Being forced to choose between two undesirable options

As with my grandfather, in most cases, no single cause or stressor leads to suicide. Our family has a history of depression. But my grandmother's death and a visit to Germany after WWII were the precipitating factors.

Assessing the Risks

The Patient Health Questionnaire (PHQ) is a tool used in primary care settings. It screens for the presence and severity of depression, anxiety, and alcohol abuse. Other disorders are also suggested. The ninth question (PHQ-9) addresses suicide. It asks, "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?"

Source: Lifeline Public Access

To assess suicide risk, the PHQ-9 is often combined with other self-assessment scales. A commonly used one is the Columbia-Suicide Severity Rating Scale (C-SSRS).

These tools help identify those at high risk. But if a scale is too sensitive, it will capture all those at risk. This may lead to overly restrictive management, e.g., involuntary hospitalization. An experienced, well-trained mental health professional needs to interview those at risk.

That interview will Include the following:

• An evaluation of the risk factors
• A search for protective factors
• The best interest of the individual
• Collateral information from loved ones
• Clinical judgment

Protective factors include the ability to cope with stress, religious beliefs, and frustration tolerance. They help define those at lower risk. But research on protective factors is sparse. Even when protective factors are present, they may not counteract significant risk.

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Assessment is not a prediction.

Assessment of risk can determine who is at risk for suicide. But it cannot predict which individual will die by suicide. Assessment tools depend upon the notable unreliability of self-reporting.

Some have claimed that these assessment tools are only slightly better than chance. A recent study concluded: There is no standard of care for predicting whether an individual will die by suicide."³

Suicide affects everyone.

A person who decides to die by suicide believes they have made a rational decision. They usually believe their life is toxic to others and the ones who love them would be better off without them. Their distorted rationalization is: Of course, it will hurt them, but they’ll get over it. I will hurt them even more than my death by continuing to live.

Families and loved ones do not share that belief. Rapt with guilt, they wonder, “Should I have seen this coming? Why didn’t I listen?” In the event of a suicide, trained and experienced mental health providers ask these same questions. But there are limitations to our clinical judgment, and the tools we have available perform poorly.

What could I have done?

When those who’ve lost a loved one from suicide ask, “What could I have done?” the painful answer is, “It is likely, there is nothing you could have done.” Because of impulsivity and poor judgment, people who only threaten suicide to manipulate others die by suicide.

My family struggled for years with guilt about not intervening in my grandfather’s death. But there was nothing we could have done to prevent it.

Sometimes, only a person's behavior suggests they are very depressed and may think of suicide. If you are concerned, ask your partner or loved one, “Have you been thinking you’d be better off dead or hurting yourself?” They may welcome your question.

No harm comes from asking about suicide.

Perhaps the most important thing to do is to offer hope: “I believe you don’t have to feel this way. I believe that someone can help.” If you receive the threat, share that information with someone. Don’t try to handle it alone.

Each threat of suicide must be taken seriously. If your partner truly wishes to die and has a plan and intention to follow through, get immediate help.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist, visit the Psychology Today Therapy Directory.