Suicide

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Suicide facts

  • Suicide is the act of purposely ending one's own life. How societies view suicide varies by culture, religion, ethnic norms, and the circumstances under which it occurs.
  • More than 800,000 people worldwide commit suicide each year -- more than 39,000 each year in the United States.
  • Self-mutilation is the act of deliberately hurting oneself without meaning to cause one's own death.
  • Physician-assisted suicide refers to a doctor ending the life of a person who is incurably ill in a way that is either painless or minimally painful for the purpose of ending the suffering of the individual.
  • The effects of suicide on the loved ones of the deceased can be devastating, resulting in suicide survivors experiencing a variety of conflicting, painful emotions.
  • Life circumstances that may immediately precede a suicide include recent discharge from a psychiatric hospital, a sudden change in how the person appears to feel, or a real or imagined loss.
  • Firearms are the most common means by which people take their lives. Other common methods include overdose of medication, asphyxiation, and hanging.
  • There are gender, age, ethnic, and geographical risk factors for suicide, as well as those based on family history, life stresses, and medical and mental-health status.
  • In children and teens, bullying and being bullied seem to be associated with committing suicide, and being bullied is apparently a risk for committing murder-suicide.
  • Warning signs that an individual is imminently planning to kill him- or herself may include the making of a will, getting his/her affairs in order, suddenly visiting or writing letters to loved ones, buying instruments of suicide, experiencing a sudden change in mood, or writing a suicide note.
  • Many people who complete suicide do not tell any health professional of their intent in the months before they do so. If they communicate a plan to anyone, it is more likely to be a friend or family member.
  • The assessment of suicide risk often involves an evaluation of the presence, severity, and duration of suicidal thoughts as part of a mental-health evaluation.
  • Treatment of suicidal thinking or a suicide attempt involves adapting immediate treatment to the sufferer's individual needs. Those with a strong social support system, who have a history of being hopeful, and have a desire to resolve conflicts may need only a brief crisis-oriented intervention. Those with more severe symptoms or less social support may need hospitalization and long-term outpatient mental-health services.
  • Treatment of any underlying emotional problem using a combination of psychotherapy, safety planning, medication, lifestyle improvement, and increasing social support remains the mainstay of suicide prevention.
  • People who are contemplating suicide are encouraged to talk to a doctor or other health professional, spiritual advisor, or immediately go to the closest emergency room or mental-health crisis center for help. Those who have experienced suicidal thinking (ideation) are commonly directed to keep a list of people to call in the event that those thoughts return. In addition to mental-health treatment, other strategies include having someone else hold all medications to prevent overdose, removing any weapons from the home, scheduling frequent stress-relieving activities, getting together with others, writing down feelings, and avoiding the use of alcohol or other drugs.
  • Techniques for coping with the suicide of a loved one include nutritious eating, getting extra rest, writing about their emotions, talking to others about the experience, thinking of ways to handle painful memories, understanding their state of mind will vary, resisting pressure to grieve by anyone else's time table, and survivors doing what is right for them.
  • To help children and adolescents cope with the suicide of a loved one, it is important to ensure they receive consistent caretaking, frequent interaction with supportive peers and adults, and an understanding of their feelings as they relate to their age.

Quick GuideMedical Ethics: Physicians' Top Ethical Dilemmas

Medical Ethics: Physicians' Top Ethical Dilemmas

Teen Suicide Warning Signs

While boys are more likely than girls to commit suicide, teens of both genders and all ages are at risk for suicide. It is especially tragic that the three leading causes of death in teens and young adults -- accident, homicide, and suicide -- all are preventable. Parents of teens should be aware of some of the warning signs of depression and suicide.

What is suicide?

Suicide is the act of purposely ending one's own life. How societies view suicide varies widely according to culture and religion. For example, many Western cultures, as well as mainstream Judaism, Islam, and Christianity tend to view killing oneself as quite negative. One myth about suicide that may be the result of this view is considering suicide (suicidal ideation) to always be the result of a mental illness. Some societies also treat a suicide attempt as if it were a crime. However, suicides are sometimes seen as understandable or even honorable in certain circumstances, as in protest to persecution (for example, a hunger strike), as part of battle or resistance (for example, suicide pilots of World War II, suicide bombers), or as a way of preserving the honor of a dishonored person (for example, killing oneself to preserve the honor or safety of family members).

More than 800,000 people worldwide committed suicide in 2012, with many more suicide attempts annually. That translates into someone dying by suicide every 40 seconds somewhere in the world. More than 39,000 people reportedly kill themselves each year in the United States, making it the 10th leading cause of death. The true number of suicides is likely higher because some deaths that were thought to be an accident, like a single-car accident, overdose, or shooting, are not recognized as being a suicide. The higher frequency of completed suicides in males versus females is consistent across the life span, but the ratio of men to women who complete suicide decreases from 3:1 in wealthier countries to closer to 1.5:1 in less wealthy countries. In the United States, boys 10-14 years of age commit suicide twice as often as their female peers. Teenage boys 15-19 years of age complete suicide five times as often as girls their age, and men 20-24 years of age commit suicide 10 times as often as women their age. Gay, lesbian, transgender, and other sexual minority youth are more at risk for thinking about and attempting suicide than heterosexual teens.

There are trends regarding the means of committing suicide as well. For example, the frequency of hanging, carbon monoxide poisoning, or other forms of self-suffocation increased from 1992 to 2006, while committing suicide by a gun has decreased during that period of time and has remained unchanged from 2012-2013.

Suicide is the second leading cause of death for people 15-29 years of age. Teen suicide statistics for youths 15-19 years of age indicate that from 1950-1990, the frequency of suicides increased by 300% and from 1990-2003, that rate decreased by 35%. However, from 1999 through 2006, the rate of suicide increased by about 1% per year and by about 2% per year from 2006 through 2014, both in the 10-24 years and the 25-64 years old age groups.

While the rate of murder-suicide remains low, the devastation it creates makes it a concerning public-health issue.

The rates of suicide can vary with the time of year, as wells as with the time of day. For example, the number of suicides by train tends to peak soon after sunset and about 10 hours earlier each day. Although professionals like police officers and dentists are thought to be more vulnerable to suicide than others, important flaws have been found in the research upon which those claims are based.

As opposed to suicidal behavior, self-mutilation is defined as deliberately hurting oneself without meaning to cause one's own death. Examples of self-mutilating behaviors include cutting any part of the body, usually of the wrists. Self-tattooing is also considered self-mutilation. Other self-injurious behaviors include self-burning, head banging, pinching, and scratching.

Physician-assisted suicide is defined as ending the life of a person who is terminally ill in a way that is either painless or minimally painful for the purpose of ending suffering of the individual. It is also called euthanasia and mercy killing. In 1997, the United States Supreme Court ruled against endorsing physician-assisted suicide as a constitutional right but allowed for individual states to enact laws that permit it to be done. As of 2016, California, Oregon, Washington, and Vermont were the only states with laws in effect that authorized physician-assisted suicide, but a number of other states are in the process of considering it. Physician-assisted suicide seems to be less offensive to people compared to assisted suicide that is done by a nonphysician, although the acceptability of both means to end life tends to increase as people age and with the severity of medical illness and the number of times the person who desires their own death repeatedly asks for such assistance.

What are the effects of suicide?

The effects of suicidal behavior or completed suicide on friends and family members are often devastating. Individuals who lose a loved one to suicide (suicide survivors) are more at risk for becoming preoccupied with the reason for the suicide while wanting to deny or hide the cause of death, wondering if they could have prevented it, feeling blamed for the problems that preceded the suicide, feeling rejected by their loved one, and stigmatized by others. Survivors may experience a great range of conflicting emotions about the deceased, feeling everything from intense emotional pain and sadness about the loss, helpless to prevent it, longing for the person they lost, questioning of their own religious beliefs, and anger at the deceased for taking their own life to relief if the suicide took place after years of physical or mental illness in their loved one. This is quite understandable given that the person they are grieving is at the same time the victim and the perpetrator of the fatal act.

Individuals left behind by the suicide of a loved one tend to experience complicated grief in reaction to that loss. Symptoms of grief that may be experienced by suicide survivors include intense emotions, like depression and guilt, as well as longings for the deceased, severely intrusive thoughts about the lost loved one, extreme feelings of isolation and emptiness, avoiding doing things that bring back memories of the departed, new or worsened appetite or sleep problems, and having no interest in activities that the sufferer used to enjoy.

What are some possible causes of suicide?

Although the reasons why people commit suicide are multifaceted and complex, life circumstances that may immediately precede someone committing suicide include recent discharge from a psychiatric hospital or a sudden change in how the person appears to feel (for example, much worse or much better). Examples of possible triggers (precipitants) for suicide are real or imagined losses, like the breakup of a romantic relationship, moving, death (especially if by suicide) of a loved one, or loss of freedom or other privileges.

Firearms are by far the most common methods by which people take their life, accounting for half of suicide deaths per year. Older people are more at risk for killing themselves using a gun compared to younger people. Another suicide method used by some individuals is by threatening police officers, sometimes even with an unloaded gun or a fake weapon. That phenomenon is commonly referred to as "suicide by cop." Although firearms are the most common way people complete suicide, trying to overdose on pills is the most common way that people attempt to kill themselves.

Quick GuideMedical Ethics: Physicians' Top Ethical Dilemmas

Medical Ethics: Physicians' Top Ethical Dilemmas

What are the risk factors and protective factors for suicide?

Ethnically, the highest suicide rates in the United States occur in non-Hispanic whites and in Native Americans. The lowest rates are in non-Hispanic blacks, Asians, Pacific Islanders, and Hispanics. Former Eastern Bloc countries currently have the highest suicide rates worldwide, while South America has the lowest. Geographical patterns of suicides are such that individuals who live in a rural area versus urban area and the western United States versus the eastern United States are at higher risk for killing themselves. The majority of suicide completions take place during the spring.

In most countries, women continue to attempt suicide more often, but men tend to complete suicide more often. Although the frequency of suicides for young adults has been increasing in recent years, elderly Caucasian males continue to have the highest rate of suicide completion. Other risk factors for taking one's life include poor access to mental-health care, single marital status, unemployment, low income, mental illness, a history of being physically or sexually abused, a personal history of suicidal thoughts, threats or behaviors, or a family history of attempting suicide. A lack of access to mental-health care has also been identified as increasing the likelihood of suicide. The means of attempting suicide can have particular risk factors as well. For example, individuals who attempt suicide by jumping from a height like a bridge may be more likely to be single, unemployed, and psychotic, while those who use firearms may more often have a history of legal issues, alcoholism, and certain personality disorders.

Data regarding mental illnesses as risk factors indicate that depression, manic depression, schizophrenia, substance abuse, eating disorders, and severe anxiety increase the probability of suicide attempts and completions. Nine out of 10 people who commit suicide have a diagnosable mental-health problem and up to three out of four individuals who take their own life had a physical illness when they committed suicide. Behaviors that tend to be linked with suicide attempts and completions include impulsivity, violence against others, and self-mutilation, like slitting one's wrists or other body parts, or burning oneself.

Risk factors for adults who commit murder-suicide include male gender, older caregiver, access to firearms, separation or divorce, depression, and drug abuse or addiction. In children and adolescents, bullying and being bullied seem to be associated with an increased risk of suicidal behaviors. Specifically regarding male teens who ultimately commit murder-suicide by school shootings, being bullied may play a significant role in putting them at risk for this outcome. Another risk factor that renders children and teens more at risk for suicide compared to adults is having someone they know commit suicide, which is called contagion or cluster formation.

Generally, the absence of mental illness and substance abuse, as well as the presence of a strong social support system, decrease the likelihood that a person will kill him- or herself. Having children who are younger than 18 years of age also tends to be a protective factor against mothers committing suicide.

What are the signs and symptoms for suicidal behavior?

Warning signs that an individual is imminently planning to kill themselves may include the person making a will, otherwise getting his or her affairs in order, suddenly visiting friends or family members (one last time), buying instruments of suicide like a gun, hose, rope, pills, or other forms of medications, a sudden and significant decline or improvement in mood, or writing a suicide note. Contrary to popular belief, many people who complete suicide do not tell their therapist or any other mental-health professional they plan to kill themselves in the months before they do so. If they communicate their plan to anyone, it is more likely to be someone with whom they are personally close, like a friend or family member.

Individuals who take their lives tend to suffer from severe anxiety or depression, symptoms of which may include moderate alcohol abuse, insomnia, severe agitation, loss of interest in activities they used to enjoy (anhedonia), hopelessness, and persistent thoughts about the possibility of something bad happening. Since suicidal behaviors are often quite impulsive, removing guns, medications, knives, and other instruments people often use to kill themselves from the immediate environment can allow the individual time to think more clearly and perhaps choose a more rational way of coping with their pain. It can also allow the person's caregivers or loved ones time to intervene.

Quick GuideMedical Ethics: Physicians' Top Ethical Dilemmas

Medical Ethics: Physicians' Top Ethical Dilemmas

How are suicidal thoughts and behaviors assessed?

The risk assessment for suicidal thoughts and behaviors performed by mental-health professionals often involves an evaluation of the presence, frequency, severity, and duration of suicidal feelings in the individuals they treat as part of a comprehensive evaluation of the person's mental health. Therefore, in addition to asking questions about family mental-health history and about the symptoms of a variety of emotional problems (for example, anxiety, depression, mood swings, bizarre thoughts, substance abuse, eating disorders, and any history of being traumatized), practitioners frequently ask the people they evaluate about any past or present suicidal thoughts (ideations), dreams, intent, and plans. If the individual has ever attempted suicide, information about the circumstances surrounding the attempt, as well as the level of dangerousness of the method and the outcome of the attempt, may be explored. Any other history of violent behavior might be evaluated. The person's current circumstances, like recent stressors (for example, end of a relationship, family problems), sources of support, and accessibility of weapons are often probed. What treatment the person may be receiving and how he or she has responded to treatment recently and in the past, are other issues mental-health professionals tend to explore during an evaluation.

Sometimes professionals assess suicide risk by using an assessment scale. One such scale is called the SAD PERSONS Scale, which identifies risk factors for suicide as follows:

  • Sex (male)
  • Age younger than 19 or older than 45 years of age
  • Depression (severe enough to be considered clinically significant)
  • Previous suicide attempt or received mental-health services of any kind
  • Excessive alcohol or other drug use
  • Rational thinking lost
  • Separated, divorced, or widowed (or other ending of significant relationship)
  • Organized suicide plan or serious attempt
  • No or little social support
  • Sickness or chronic medical illness

What is the treatment for suicidal thoughts and behaviors? What types of specialists treat people who are suicidal?

Those who treat people who attempt suicide tend to adapt immediate treatment to the person's individual needs. Those who have a responsive and intact family, good friendships, generally good social supports, and who have a history of being hopeful and have a desire to resolve conflicts may need only a brief crisis-oriented intervention. However, those who have made previous suicide attempts, have shown a high degree of intent to kill themselves, seem to be suffering from either severe depression or other mental illness, are abusing alcohol or other drugs, have trouble controlling their impulses, or have families who are unable or unwilling to commit to counseling are at higher risk and may need psychiatric hospitalization to prevent a repeat attempt in the days following the most recent attempt by providing close monitoring (for example, suicide watch) and long-term outpatient mental-health services to achieve recovery from their suicidal thoughts or actions.

Talk therapy (psychotherapy) that focuses on helping the person understand how their thoughts and behaviors affect each other (cognitive behavioral therapy) has been found to be an effective treatment for many people who struggle with thoughts of harming themselves. School intervention programs in which teens are given support and educated about the risk factors, symptoms, and ways to manage suicidal thoughts in themselves and how to engage adults when they or a peer expresses suicidal thinking have been found to decrease the number of times adolescents report attempting suicide.

Although concerns have been raised about the possibility that antidepressant medications increase the frequency of suicide attempts, mental-health professionals try to put those concerns in the context of the need to treat the severe emotional problems that are usually associated with attempting suicide and the fact that the number of suicides that are completed by mentally ill individuals seems to decrease with treatment. The effectiveness of medication treatment for depression in teens is supported by research, particularly when medication is combined with psychotherapy. In fact, concern has been expressed that the reduction of antidepressant prescribing since the U.S. Food and Drug Administration required that warning labels be placed on these medications may be related to the 18.2% increase in U.S. youth suicides from 2003-2004 after a decade of steady decrease. While the use of specific antidepressants has been associated with lower suicide rates in adolescents over the long term, uncommon short-term side effects of serotonergic antidepressants (for example, fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], escitalopram [Lexapro], or vortioxetine [Trintellix]) may include an increase in suicide. Therefore, most practitioners consider antidepressant medication an important part of treating depression while closely monitoring their patients' progress to prevent suicide.

Mood-stabilizing medications like lithium (Lithobid) -- as well as medications that address bizarre thinking and/or severe anxiety, like clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify) -- have also been found to decrease the likelihood of individuals killing themselves.

How can people cope with suicidal thoughts?

In the effort to cope with suicidal thoughts, silence is the enemy. Suggestions for helping people survive suicidal thinking include engaging the help of a doctor or other health professional, a spiritual advisor, or by immediately calling a suicide hotline or going to the closest emergency room or mental-health crisis center. In order to prevent acting on thoughts of suicide, it is often suggested that individuals who have experienced suicidal thinking keep a written or mental list of people to call in the event that suicidal thoughts come back. Other strategies include having someone hold all medications to prevent overdose, removing knives, guns, and other weapons from the home, scheduling stress-relieving activities every day, getting together with others to prevent isolation, writing down feelings, including positive ones, and avoiding the use of alcohol or other drugs.

How can people cope with the suicide of a loved one?

Grief that is associated with the death of a loved one from suicide presents intense and unique challenges. In addition to the already significant pain endured by anyone who loses a loved one, suicide survivors may feel guilty about having not been able to prevent their loved one from killing themselves and the myriad conflicting emotions already discussed. Friends and family may be more likely to experience regret about whatever problems they had in their relationship with the deceased, and they may even feel guilty about living while their loved one is not. Therefore, individuals who lose a loved one from suicide are more at risk for becoming preoccupied with the reason for the suicide while perhaps wanting to deny or hide the cause of death, wondering if they could have prevented it, feeling blamed for the problems that preceded the suicide, feeling rejected by their loved one and stigmatized by others.

Some self-help techniques for coping with the stress associated with the suicide of a loved one include avoiding isolation by staying involved with others, sharing the experience by joining a support group or keeping a journal, thinking of ways to handle it when other life experiences trigger painful memories about the loss, understanding that getting better involves feeling better some days and worse on other days, resisting pressure to get over the loss, and the suicide survivor's doing what is right for them in their efforts to recover. Many people, particularly parents of children who commit suicide, take some comfort in being able to use this terrible experience as a way to establish a memorial to their loved one. That can take the form of everything from writing a poem, planting a tree, or painting a mural in honor of the departed to establishing a scholarship fund in their loved one's name to teaching others about how to survive a child's suicide. Generally, coping tips for grieving a death through suicide are nearly as different and numerous as there are bereaved individuals. The bereaved person's caring for him- or herself through continuing nutritious and regular eating habits and getting extra, although not excessive, rest can help strengthen their ability to endure this very difficult event.

Quite valuable tips for journaling as an effective way of managing bereavement rather than just stirring up painful feelings are provided by the Center for Journal Therapy. While encouraging those who choose to write a journal to apply no strict rules to the process as part of suicide recovery, some of the ideas encouraged include limiting the time journaling to 15 minutes per day or less to decrease the likelihood of worsening grief, writing how one imagines his or her life will be a year from the date of the suicide, and clearly identifying feelings to allow for easier tracking of the individual's grief process.

To help children and adolescents cope emotionally with the suicide of a friend or family member, it is important to ensure they receive consistent caretaking and frequent interaction with supportive adults. All children and teens can benefit from being reassured they did not cause their loved one to kill themselves, going a long way toward lessening the developmentally appropriate tendency children and adolescents have for blaming themselves and any angry feelings they may have harbored against their lost loved one for the suicide. For school-aged and older children, appropriate participation in school, social, and extracurricular activities is necessary to a successful resolution of grief. For adolescents, maintaining positive relationships with peers becomes important in helping teens figure out how to deal with a loved one's suicide. Depending on the adolescent, they even may find interactions with peers and family more helpful than formal sources of support like their school counselor.

Is it possible to prevent a suicide attempt?

For the population at large, suicide-prevention strategies include increasing access to health care, promoting mental health, avoidance of drug use, and restricting access to means to complete suicide. Responsible media reporting to raise mental-health and suicide awareness, as well as how to report suicides and other violence that occurs are other suicide-prevention strategies that are often used in general populations.

Suicide-prevention measures for individuals who have a mental-health history following a psychiatric hospitalization usually involve mental-health professionals trying to implement a comprehensive outpatient treatment plan prior to the individual being discharged. This is all the more important since many people fail to comply with outpatient therapy after leaving the hospital. It is often recommended that all firearms and other weapons be removed from the home, because the individual may still find access to guns and other dangerous objects stored in their home, even if locked. It is further often recommended that sharp objects and potentially lethal medications be locked up as a result of the attempt.

Vigorous treatment of the underlying psychiatric disorder is important in decreasing short-term and long-term risk. Contracting with the person against suicide has not been shown to be especially effective in preventing suicidal behavior, but the technique may still be helpful in assessing risk, since hesitation or refusal to agree to refrain from harming oneself or to fail to agree to tell a specified person may indicate an intent to harm oneself. Contracting might also help the individual identify sources of support he or she can call upon in the event that suicidal thoughts recur.

What is the prognosis for someone who has made a suicide attempt or threat?

While most people who attempt suicide do not ultimately die by suicide, those who have tried to kill themselves are at much higher risk of completing suicide compared to those who have never attempted to do so. People who attempt suicide have been found to be at risk for developing symptoms of posttraumatic stress disorder (PTSD), with the suicide attempt being the traumatic event. This has been found to be more likely the more serious the suicide attempt and the more steps the person took in an effort to avoid detection before their demise. Given the potentially fatal prognosis of attempting suicide, the need for treatment is all the more important.

Where can people get help for suicidal thoughts?

American Association of Suicidology
http://www.suicidology.org
202-237-2280

American Foundation for Suicide Prevention
http://www.afsp.org

Jason Foundation
http://www.jasonfoundation.com

National Suicide Prevention Hotline
800-SUICIDE (784-2433)
http://www.suicide.org

National Suicide Prevention Lifeline
800-273-TALK (8255)

Society for the Prevention of Teen Suicide
http://sptsusa.org

Substance Abuse and Mental Health Services Administration (SAMHSA)
http://www.samhsa.gov

Suicide Prevention Advocacy Network (SPAN)
http://www.spanusa.org

Yellow Ribbon Suicide Prevention Program
http://www.yellowribbon.org/

The future

How to best assess the risk of someone committing suicide continues to be an elusive challenge for health professionals, so this is an appropriate goal for future research. The best way to achieve the balance between using psychiatric medication to treat any underlying conditions that may result in suicidal thoughts and the potential side effects of those medications is an ongoing issue in suicide prevention.

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Rao, K.N., C.Y. Sudarshan, and S. Begum. "Self-injurious Behavior: A Clinical Appraisal." Indian Journal Psychiatry 50.4 Oct.-Dec. 2008: 288-297.

Rask, K., Kaunonen, M. and Paunonen-Ilmonen, M. "Adolescent Coping With Grief After the Death of a Loved One." International Journal of Nursing Practice 8(3) June 2002: 137-142.

Reid, W.H. "Prognosis after suicide attempt: Standard of care and the consequences of not meeting it." Journal of Psychiatric Practice 15.2 March 2009: 141-144.

Reinherz, H.Z., Tanner, J.L. and Berger, S.R. "Adolescent Suicidal Ideation as Predictive of Psychopathology, Suicidal Behavior and Compromised Functioning at Age 30." American Journal of Psychiatry 163 (2006): 1226-3122.

Reuter-Rice, K. "Male Adolescent Bullying and the School Shooter." Journal of School Nursing  24.6 (2008): 350-359.

Russell, S.T., and K. Joyner. "Adolescent Sexual Orientation and Suicide Risk: Evidence From a National Study." American Journal of Public Health 91.8 Aug. 2001: 1276-1281.

Shain, B.N. "Committee on Adolescence. Suicide and Suicide Attempts in Adolescents." Pediatrics 120.3 Sept. 2007: 669-676.

Sher, L. "Preventing Suicide." Quarterly Journal of Medicine 97.10 (2004): 677-680.

Silva, M.J. and Vitiello, B. "The Treatment for Adolescents With Depression Study (TADS): Methods and Message at 12 Weeks." Journal of the American Academy of Child and Adolescent Psychiatry 45 (2006): 1393-1403.

Soreff, S. "Suicide." eMedicine.com. Sept. 28, 2006.

Switzerland. World Health Organization. Preventing Suicide: A Global Imperative. Geneva, Switzerland: World Health Organization, 2014.

Switzerland. World Health Organization. "Suicide rates per 100,000 by country, year and sex." (2013) <http://www.who.int/mental_health/prevention/suicide_rates/en/>.

United States. Centers for Disease Control and Prevention. "National Suicide Statistics at a Glance 2009." Sept. 30, 2009. <http://www.cdc.gov/violenceprevention/suicide/statistics/aag.html>.

van Houwelingen, C.A., and D.G. Beersma. "Seasonal Changes in 24-Hour Patterns of Suicide Rates: A Study on Train Suicides in the Netherlands." Journal of Affective Disorders 66.2-3 Oct. 2001: 215-223.

Washington State Legislature. Initiative Measure Number 1000. The Washington Death with Dignity Act 2008 January.

Xu, J., S.L. Murphy, K.D. Kochanek, and B.A. Bastian. "Deaths: Final data for 2013." National Vital Statistics Reports 64.2 February 2016: 1-119.

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Reviewed on 10/31/2016
References
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Rao, K.N., C.Y. Sudarshan, and S. Begum. "Self-injurious Behavior: A Clinical Appraisal." Indian Journal Psychiatry 50.4 Oct.-Dec. 2008: 288-297.

Rask, K., Kaunonen, M. and Paunonen-Ilmonen, M. "Adolescent Coping With Grief After the Death of a Loved One." International Journal of Nursing Practice 8(3) June 2002: 137-142.

Reid, W.H. "Prognosis after suicide attempt: Standard of care and the consequences of not meeting it." Journal of Psychiatric Practice 15.2 March 2009: 141-144.

Reinherz, H.Z., Tanner, J.L. and Berger, S.R. "Adolescent Suicidal Ideation as Predictive of Psychopathology, Suicidal Behavior and Compromised Functioning at Age 30." American Journal of Psychiatry 163 (2006): 1226-3122.

Reuter-Rice, K. "Male Adolescent Bullying and the School Shooter." Journal of School Nursing  24.6 (2008): 350-359.

Russell, S.T., and K. Joyner. "Adolescent Sexual Orientation and Suicide Risk: Evidence From a National Study." American Journal of Public Health 91.8 Aug. 2001: 1276-1281.

Shain, B.N. "Committee on Adolescence. Suicide and Suicide Attempts in Adolescents." Pediatrics 120.3 Sept. 2007: 669-676.

Sher, L. "Preventing Suicide." Quarterly Journal of Medicine 97.10 (2004): 677-680.

Silva, M.J. and Vitiello, B. "The Treatment for Adolescents With Depression Study (TADS): Methods and Message at 12 Weeks." Journal of the American Academy of Child and Adolescent Psychiatry 45 (2006): 1393-1403.

Soreff, S. "Suicide." eMedicine.com. Sept. 28, 2006.

Switzerland. World Health Organization. Preventing Suicide: A Global Imperative. Geneva, Switzerland: World Health Organization, 2014.

Switzerland. World Health Organization. "Suicide rates per 100,000 by country, year and sex." (2013) <http://www.who.int/mental_health/prevention/suicide_rates/en/>.

United States. Centers for Disease Control and Prevention. "National Suicide Statistics at a Glance 2009." Sept. 30, 2009. <http://www.cdc.gov/violenceprevention/suicide/statistics/aag.html>.

van Houwelingen, C.A., and D.G. Beersma. "Seasonal Changes in 24-Hour Patterns of Suicide Rates: A Study on Train Suicides in the Netherlands." Journal of Affective Disorders 66.2-3 Oct. 2001: 215-223.

Washington State Legislature. Initiative Measure Number 1000. The Washington Death with Dignity Act 2008 January.

Xu, J., S.L. Murphy, K.D. Kochanek, and B.A. Bastian. "Deaths: Final data for 2013." National Vital Statistics Reports 64.2 February 2016: 1-119.

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