Learning Objectives

  • Discuss the relationship between mood disorders and suicidal ideation as well as factors associated with suicide
Someone is clasping another person's hand in their hands.

Figure 1. Having protective factors like social support is crucial to coping with emotional pain.

For some people with mood disorders, the extreme emotional pain they experience becomes unendurable. Overwhelmed by hopelessness, devastated by incapacitating feelings of worthlessness, and burdened with the inability to adequately cope with such feelings, they may consider suicide to be a reasonable way out. Suicide, defined by the CDC as “death caused by self-directed injurious behavior with any intent to die as the result of the behavior” (CDC, 2013a), in a sense represents an outcome of several things going wrong all at the same time (Crosby, Ortega, & Melanson, 2011). Not only must the person be biologically or psychologically vulnerable, but they must also have the means to perform the suicidal act, and must lack the necessary protective factors (e.g., social support from friends and family, religion, coping skills, and problem-solving skills) that provide comfort and enable one to cope during times of crisis or great psychological pain (Berman, 2009).

Suicide is not listed as a disorder in the DSM-5; however, suffering from a mental disorder—especially a mood disorder—poses the greatest risk for suicide. Around 90% of those who complete suicides have a diagnosis of at least one mental disorder, with mood disorders being the most frequent (Fleischman, Bertolote, Belfer, & Beautrais, 2005). In fact, the association between major depressive disorder and suicide is so strong that one of the criteria for the disorder is thoughts of suicide, as discussed above (APA, 2013). Suicide rates can be difficult to interpret because some deaths that appear to be accidental may in fact be acts of suicide (e.g., automobile crash).

Antidepressant medications may also have an effect on suicidal thoughts as a troubling side effect.[1] Studies have shown that the use of antidepressants is correlated with an increased risk of suicidal behavior and thinking (suicidality) in those aged under 25. This problem has been serious enough to warrant government intervention by the FDA to warn of the increased risk of suicidality during antidepressant treatment. According to the FDA, the heightened risk of suicidality occurs within the first one to two months of treatment.
The National Institute for Health and Care Excellence (NICE) places the excess risk in the “early stages of treatment.” A meta-analysis suggests that the relationship between antidepressant use and suicidal behavior or thoughts is age-dependent. Compared with a placebo, the use of antidepressants is associated with an increase in suicidal behavior or thoughts among those 25 or younger (OR=1.62). There is no effect or possibly a mild protective effect among those aged 25 to 64 (OR=0.79). Antidepressant treatment has a protective effect against suicidality among those aged 65 and over (OR=0.37). Nevertheless, investigations into U.S. suicide rates have uncovered these facts:
  • Suicide was the 10th leading cause of death for all ages in 2010 (Centers for Disease Control and Prevention [CDC], 2012).
  • There were 38,364 suicides in 2010 in the United States—an average of 105 each day (CDC, 2012).
  • Suicide among males is four times higher than among females and accounts for 79% of all suicides; firearms are the most commonly used method of suicide for males, whereas poisoning is the most commonly used method for females (CDC, 2012).
  • From 1991 to 2003, suicide rates were consistently higher among those 65 years and older. Since 2001, however, suicide rates among those ages 25–64 have risen consistently, and, since 2006, suicide rates have been greater for those ages 65 and older (CDC, 2013b). This increase in suicide rates among middle-aged Americans has prompted concern in some quarters that baby boomers (individuals born between 1946–1964) who face economic worry and easy access to prescription medication may be particularly vulnerable to suicide (Parker-Pope, 2013).
  • The highest rates of suicide within the United States are among American Indians/Alaskan natives and non-Hispanic Whites (CDC, 2013b).
  • Suicide rates vary across the United States, with the highest rates consistently found in the mountain states of the west (Alaska, Montana, Nevada, Wyoming, Colorado, and Idaho) (Berman, 2009).

Contrary to popular belief, suicide rates peak during the springtime (April and May), not during the holiday season or winter. In fact, suicide rates are generally lowest during the winter months (Postolache et al., 2010).

Celebrity Suicides

Anthony Bourdain

Figure 2. Celebrity chef Anthony Bourdain.

In early June 2018, celebrity chef Anthony Bourdain was working on an episode of Parts Unknown in Strasbourg, with his frequent collaborator and friend Éric Ripert. On June 8, Ripert became worried when Bourdain had missed dinner and breakfast. He subsequently found Bourdain dead of an apparent suicide by hanging in his room at Le Chambard hotel in Kaysersberg near Colmar. Bourdain was 61 years old.

Christian de Rocquigny du Fayel, the public prosecutor for Colmar, said Bourdain’s body bore no signs of violence and the suicide appeared to be an impulsive act. Rocquigny du Fayel disclosed that Bourdain’s toxicology results were negative for narcotics, showing only a trace of a therapeutic non-narcotic medication. Bourdain’s body was cremated in France on June 13, 2018, and his ashes were returned to the United States two days later.
Bourdain’s mother, Gladys Bourdain, told The New York Times, “He is absolutely the last person in the world I would have ever dreamed would do something like this.”

Following the news of Bourdain’s death, various celebrity chefs and other public figures expressed sentiments of condolence. Among them were fellow chefs Andrew Zimmern and Gordon Ramsay and former astronaut Scott Kelly. CNN issued a statement, saying that Bourdain’s “talents never ceased to amaze us and we will miss him very much.” Former U.S. President Barack Obama, who dined with Bourdain in Vietnam on an episode of Parts Unknown, wrote on Twitter, “He taught us about food—but more importantly, about its ability to bring us together. To make us a little less afraid of the unknown.” On June 8, 2018, CNN aired Remembering Anthony Bourdain, a tribute program.

In the days following Bourdain’s death, fans paid tribute to him outside his now-closed former place of employment, Brasserie Les Halles. Cooks and restaurant owners gathered together and held tribute dinners and memorials and donated net sales to the National Suicide Prevention Lifeline.

Bourdain’s death came just days after the suicide of designer Kate Spade.

Watch this video from CBS in the aftermath of Bourdain’s death as it discusses some of the risk factors for suicide.

You can view the transcript for “Anthony Bourdain’s death: Dr. LaPook on suicide risk factors” here (opens in new window).

Risk Factors for Suicide

Bottles of alcohol.

Figure 3. Alcoholism is a significant risk factor for suicide.

Suicidal risk is especially high among people with substance abuse problems. Individuals with alcohol dependence are at 10 times greater risk for suicide than the general population (Wilcox, Conner, & Caine, 2004). The risk of suicidal behavior is especially high among those who have made a prior suicide attempt. Among those who attempt suicide, 16% make another attempt within a year and over 21% make another attempt within four years (Owens, Horrocks, & House, 2002). Suicidal individuals may be at high risk for terminating their life if they have a lethal means in which to act, such as a firearm in the home (Brent & Bridge, 2003). Withdrawal from social relationships, feeling as though one is a burden to others, and engaging in reckless and risk-taking behaviors may be precursors to suicidal behavior (Berman, 2009). A sense of entrapment or feeling unable to escape one’s miserable feelings or external circumstances (e.g., an abusive relationship with no perceived way out) predicts suicidal behavior (O’Connor, Smyth, Ferguson, Ryan, & Williams, 2013). Tragically, reports of suicides among adolescents following instances of cyberbullying have emerged in recent years. In one widely publicized case, Phoebe Prince, a 15-year-old high school student in Massachusetts, committed suicide following incessant harassment and taunting from her classmates via texting and Facebook (McCabe, 2010).

Suicides can have a contagious effect on people. For example, another’s suicide, especially that of a family member, heightens one’s risk of suicide (Agerbo, Nordentoft, & Mortensen, 2002). Additionally, widely publicized suicides tend to trigger copycat suicides in some individuals. One study examining suicide statistics in the United States from 1947 to 1967 found that the rates of suicide skyrocketed for the first month after a suicide story was printed on the front page of the New York Times (Phillips, 1974). Austrian researchers found a significant increase in the number of suicides by firearms in the three weeks following extensive reports in Austria’s largest newspaper of a celebrity suicide by gun (Etzersdorfer, Voracek, & Sonneck, 2004). A review of 42 studies concluded that media coverage of celebrity suicides is more than 14 times more likely to trigger copycat suicides than is coverage of non-celebrity suicides (Stack, 2000). This review also demonstrated that the medium of coverage is important: televised stories are considerably less likely to prompt a surge in suicides than are newspaper stories. Research suggests that a trend appears to be emerging whereby people use online social media to leave suicide notes, although it is not clear to what extent suicide notes on such media might induce copycat suicides (Ruder, Hatch, Ampanozi, Thali, & Fischer, 2011). Nevertheless, it is reasonable to conjecture that suicide notes left by individuals on social media may influence the decisions of other vulnerable people who encounter them (Luxton, June, & Fairall, 2012).

One possible contributing factor in suicide is brain chemistry. Contemporary neurological research shows that disturbances in the functioning of serotonin are linked to suicidal behavior (Pompili et al., 2010). Low levels of serotonin predict future suicide attempts and suicide completions, and low levels have been observed post-mortem among suicide victims (Mann, 2003). Serotonin dysfunction, as noted earlier, is also known to play an important role in depression; low levels of serotonin have also been linked to aggression and impulsivity (Stanley et al., 2000). The combination of these three characteristics constitutes a potential formula for suicide—especially violent suicide. A classic study conducted during the 1970s found that patients with major depressive disorder who had very low levels of serotonin attempted suicide more frequently and more violently than did patients with higher levels (Asberg, Thorén, Träskman, Bertilsson, & Ringberger, 1976; Mann, 2003).

Suicidal thoughts, plans, and even off-hand remarks (“I might kill myself this afternoon”) should always be taken extremely seriously. People who contemplate terminating their life need immediate help. Below are links to two excellent websites that contain resources (including hotlines) for people who are struggling with suicidal ideation, have loved ones who may be suicidal, or who have lost loved ones to suicide: American Foundation for Suicide Prevention and American Association of Suicidology.

Watch It: Treatments for Suicide Prevention

Effective treatments for suicide are dialectical behavioral therapy (DBT), cognitive therapy for suicide prevention (CT-SP), and brief cognitive behavioral therapy (BCBT). These plans generally begin with a safety plan, then learning methods to manage emotions (such as mindfulness), changing unhealthy coping mechanisms, and managing thoughts.

You can view the transcript for “Suicide Prevention Treatment” here (opens in new window).

Dialectical Behavior Therapy

The most notable and heavily researched treatment that has been shown to reduce suicidal behaviors regardless of the intent to die, is dialectical behavior therapy (DBT). Dialectical behavior therapy (DBT) has four main components: individual therapy, skills training, phone coaching, and a consultation team. DBT’s main goal is to teach the patient skills to regulate emotions and improve relationships with others (suicidality is always targeted at the forefront of care). Skills are taught through validation and acceptance with a genuine focus on behavioral change. DBT was one of the first evidence-based treatments shown to be effective in decreasing repetitive self-harm behaviors and suicide attempts. More recent results have demonstrated DBT’s continued impact on decreasing suicidal behaviors among high risk individuals such as those with borderline personality disorder, and decreasing suicide ideation and self-harm among adolescents. However, while DBT has shown impressive results in managing suicidal behaviors, it is not solely devoted to treating suicidality, and replicated results for reliably decreasing suicidal ideation are not consistent across all DBT randomized controlled trials (RCTs).

Cognitive Therapy for Suicide Prevention

Another effective treatment that targets the “suicidal mode” is cognitive therapy for suicide prevention (CT-SP). Cognitive therapy for suicide prevention (CT-SP) treats the clinical characteristics of suicidal behaviors by using various cognitive therapy techniques, which have proven successful for treating an extensive array of psychiatric disorders. In a well-powered randomized controlled trial (RCT) (with a deliberately longer follow-up period than previous RCTs—18 months), Brown and colleagues[2] found that patients in CT-SP treatment were 50% less likely to attempt suicide compared to those in the usual care treatment group. The researchers also found significant reductions in levels of depression and hopelessness in the CT-SP treatment group compared to the control. This study showed high internal validity; replication of the data in a real world setting (e.g., a community-based outpatient setting) with varied samples (e.g., those who have not attempted suicide, but with severe ideation) is a pending next step for the researchers of CT-SP.

Brief Cognitive Behavior Therapy

Brief cognitive behavior therapy (BCBT) was used in one well-powered randomized controlled trial (RCT) with suicidal, active duty U.S. Army soldiers and was shown to be effective for reducing suicide attempts.[3] As its name indicates, this modality is brief (i.e., 12 sessions) to accommodate short-term treatment environments. This variation of CBT suicide-focused care emphasizes common effective treatment elements, developing skills (e.g., emotion regulation, mindfulness), a focus on the suicidal mode, and the development of self-management. Rudd and colleagues followed soldiers for 24 months and found that compared to treatment as usual, those in the brief cognitive behavior therapy (BCBT) group were 60% less likely to attempt suicide.[4]

Try It


brief cognitive behavior therapy: a modified CBT program with 12 session designed to help patients after a suicide attempt; they develop skills and self-management techniques
cognitive therapy for suicide prevention: a type of CBT for patients following a suicide attempt in which they are taught new ways of thinking during suicidal episodes
dialectical behavior therapy: a therapy focused on teaching a patient skills to regulate emotions and improve relationships with others
suicidal ideation: thoughts of death by suicide, thinking about or planning suicide, or making a suicide attempt
suicide: death caused by intentional, self-directed injurious behavior

  1. Stone M, Laughren T, Jones ML, Levenson M, Holland PC, Hughes A, Hammad TA, Temple R, Rochester G (2009). "Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration". BMJ. 339: b2880. doi:10.1136/bmj.b2880. PMC 2725270. PMID 19671933
  2. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT JAMA. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. 2005 Aug 3; 294(5):563-70.
  3. Rudd MD, Bryan CJ, Wertenberger EG, Peterson AL, Young-McCaughan S, Mintz J, Williams SR, Arne KA, Breitbach J, Delano K, Wilkinson E, Bruce TO. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015 May; 172(5):441-9.
  4. Jobes, D. A., & Chalker, S. A. (2019). One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths. International journal of environmental research and public health, 16(19), 3606.