September 27, 2021

By Mark D. Rego, MD

man hugging child on couch

Each year, more than half a million people arrive at emergency rooms because they are contemplating suicide or because they have already hurt themselves. Despite the care they received, in the year that follows the visit, they are still at a high risk for suicide.

Of course, that outcome is a nightmare scenario for their loved ones. In the aftermath of suicide, family and friends often carry the burden of wondering what their role “should” have been in preventing the tragedy.

Accordingly, friends and loved ones deserve some guideposts for navigating what to do if someone they care about is at risk for suicide.


Observing for Signs of Suicidality

Predicting when someone is about to attempt to take their life is difficult. Indeed, that task should be left to the treating clinician. Your “job,” however, can involve watching for direct and indirect signs of suicidality and severe distress.

Direct signs are when someone you care about says they feel like hurting or killing themselves. Indirect signs are more subtle — the early warning signs that someone is worsening. For instance, they might make negative statements like, “life is not worth it anymore,” or “I am useless.” They may try to gather the means for self-harm, like saving up pills or acquiring a weapon.

Beyond noting the harmful behavior, you should not try to determine what the risk is. Rather, you should go directly to them and discuss what you’ve observed. Then, you can contact their clinician or other help. If a clinician is not available, then contact someone respected by the patient, like an authority figure, faith leader or anyone they feel close to and trust. Using this approach, you will be able to gather more information to share with the treatment team.


Talking Effectively About Suicidality

When discussing suicide, remember the following:

  1. You will not make someone suicidal by saying the word “suicide” or asking about how they might hurt themselves. In fact, effective interventions include talking about suicide directly.
  2. Showing that you are comfortable with the discussion takes some of the power and “shock” out of thoughts of suicidality. Such thoughts may be normal for your loved one. If so, it will be reassuring that they can discuss the topic without upsetting you. If these thoughts are new, it may be scary for them. In this case, your calm and serious tone may be reassuring.
  3. You should ask your loved one about a specific plan. How will they do it? When? Inquire about the specifics. Let them know that you’d like them to speak with their treatment team. If they refuse, you will need to contact the treatment team yourself. (Remember HIPPA and other laws about confidentiality all make exceptions for emergencies that may risk life and death.) You should not get into a struggle during this conversation. If the situation feels out of control, you can call 911 and then the treating clinician for help.

Naturally, there are times when the situation may get more complicated. What if, for example, you cannot be sure if your family member is being open and truthful with you? This (and other complexities) certainly happen. Rely on guidance from the treating clinician when you’re feeling uncertain.


Knowing What Proper Treatment Looks Like

As you help your friend or family member navigate treatment, it’s important that you know what sufficient mental health care looks like. Unfortunately, it’s common for patients to call their clinicians for help and to receive a voicemail instructing them to go to the ER or call 911 for any problems after office hours. This response is a sign that they may need a different clinician.

A visit to the ER is necessary in significant emergencies but can often be avoided. Unless urgent action is needed, it is better to work things out with the clinician, as they know the patient and can use the situation as a learning experience to manage difficulties in the future.

If the clinician feels a visit to the ER is necessary for safety, then they should make that decision and call the ER in order to give appropriate history and be in touch with the staff there to discuss follow-up.

Ideally, a clinician should follow three principles whenever they work with a patient thinking of suicide.

  1. Provide protection when a patient cannot protect themselves. This means setting expectations of their patient (and communicating to loved ones), such as not being alone for extended periods of time, coming in for an emergency appointment if they need to, etc. Clinicians will also be the ones to determine if a medication adjustment or a hospital visit is needed.
  2. Make sure their patient feels connected. This connection could be to the practitioner, a family member, anyone. People who are suicidal usually feel disconnected from others. This hinders them from seeing the ramifications of suicide.
  3. Treat the underlying condition with medication. Medications, particularly those for anxiety and insomnia, have proven to decrease suicidality.

Your loved one may also need therapy around a recent crisis, like a break-up, job loss or other interpersonal problem. These interventions are an important part of treatment as they can decrease the pain from certain life events.

Ultimately, if they have had significant suicidal ideation, made a suicide attempt, been psychiatrically hospitalized or have a serious mental health condition, then it’s important to be prepared for a crisis.

Your role is not to know what treatment your loved one needs or when they need a specific intervention. Rather, it is to be a form of support and connection for them and a form of guidance for their providers. No one knows a person better than their friends and family members, making you an invaluable asset to the treatment team.


Dr. Mark D. Rego is a psychiatrist with 30 years of experience. He spent 25 years in practice and has now written a book, “Frontal Fatigue. The Impact of Modern Life and Technology on Mental Illness.” It will be out Oct. 12, 2021. Visit for more information.

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