PTSD and Suicide

This fact sheet explores the relationship between PTSD and suicide. It also addresses important questions about understanding and coping with suicide. This fact sheet is not intended to replace mental health assistance obtained from a professional.

Does PTSD increase an individual’s suicide risk?

A large body of research indicates that there is a correlation between PTSD and suicide. There is evidence that traumatic events such as sexual abuse, combat trauma, rape, and domestic violence generally increase a person’s suicide risk. Considerable debate exists, however, about the reason for this increase. Whereas some studies suggest that suicide risk is higher due to the symptoms of PTSD, others claim that suicide risk is higher in these individuals because of related psychiatric conditions. Some studies that point to PTSD as the cause of suicide suggest that high levels of intrusive memories can predict the relative risk of suicide. High levels of arousal symptoms and low levels of avoidance have also been shown to predict suicide risk. In contrast, other researchers have found that conditions that co-occur with PTSD, such as depression, may be more predictive of suicide. Furthermore, some cognitive styles of coping, such as using suppression to deal with stress, may be additionally predictive of suicide risk in individuals with PTSD.

Given the high rate of PTSD in veterans, considerable research has examined the relation between PTSD and suicide in this population. Multiple factors contribute to suicide risk in veterans. Some of the most common factors are listed below:

• male gender
• alcohol abuse
• family history of suicide
• older age
• poor social-environmental support (exemplified by homelessness and unmarried status)
• possession of firearms
• the presence of medical and psychiatric conditions (including combat-related PTSD) associated with suicide

Currently there is debate about the exact influence of combat-related trauma on suicide risk. For those veterans who have PTSD as a result of combat trauma, however, it appears that the highest relative suicide risk is in veterans who were wounded multiple times or hospitalized for a wound. This suggests that the intensity of the combat trauma, and the number of times it occurred, may influence suicide risk in veterans with PTSD. Other research on veterans with combat-related PTSD suggests that the most significant predictor of both suicide attempts and preoccupation with suicide is combat-related guilt. Many veterans experience highly intrusive thoughts and extreme guilt about acts committed during times of war. These thoughts can often overpower the emotional coping capacities of veterans.

Reasons for suicide

Individuals who have lost someone to suicide often question why that person chose to end his or her life. Unfortunately, there is no easy answer to this question. Suicide often appears to be related to environmental stresses or traumatic events, but it is also the case that some individuals commit suicide without any identifiable reason. Although survivors will always feel devastation and confusion when a loved one commits suicide, available research may help survivors better understand some common reasons for suicide.

Specific reasons for suicide are as diverse as the individuals who commit it. Nevertheless, there are some common causal factors that appear to be related to suicide. For example, more than 90% of suicide victims have a significant psychiatric illness at the time of their death. These illnesses are often both undiagnosed and untreated. The two most common psychiatric conditions associated with suicide are mood disorders and substance abuse. When an individual has both a mood disorder and a substance abuse issue, the risk of suicide is much higher. This is especially the case for adolescents and young adults. This research suggests that the presence of mental illness is a primary contributor to the cause of suicide. For individuals who suffer from clinical depression specifically, of utmost concern are those who exhibit open aggression, anxiety, or agitation, as these factors significantly increase the risk of suicide.

Some researchers suggest that suicide can be understood as a type of coping mechanism for individuals who feel overwhelmed and trapped by their situations. For these people, suicide is seen as a way of dealing with extremely strong negative emotions through escape. This conceptualization of suicide is exemplified by the relation between suicide rates and media coverage, particularly in the young. Research reveals that the magnitude of increase in suicides following a suicide story is proportional to the amount, duration, and prominence of media coverage. These data suggest that suicide is more likely to occur when it is no longer perceived as “taboo” and instead is seen as a viable coping method for stress. This hypothesis of suicide as a coping device is further supported by evidence that a family history of suicide greatly increases an individual’s suicide risk, regardless of the presence of mental illness.

When trying to understand suicide, some helpful questions to consider are:

• Did the individual ever receive treatment for depression or another mental disorder?
• Did the individual have a problem with substance abuse?
• Did the individual have a history of suicide attempts?
• Did the individual have a family history of suicide attempts?

Suicide as a traumatic event

A considerable amount of research examines exposure to suicide as a traumatic event. Studies show that trauma from exposure to suicide can contribute to PTSD. In particular, adults and adolescents are more likely to develop PTSD as a result of exposure to suicide if one or more of the following conditions are true: if they witness the suicide, if they are very connected with the person who dies, or if they have a history of psychiatric illness. However, relative to other traumatic events, there appears to be nothing unique about developing PTSD as a consequence of exposure to suicide. Studies do show, however, that traumatic grief is more likely to arise after exposure to traumatic death such as suicide. Traumatic grief refers to a syndrome in which individuals experience functional impairment, a decline in physical health, and suicidal ideation. These symptoms occur independent of other conditions such as depression and anxiety. For more information about traumatic grief please refer to the Managing Grief fact sheet.

What can I do?

I am suicidal

Everyone feels down occasionally. Feeling suicidal, however, is not normal. If you have thoughts about hurting yourself, it is important to seek professional help. Many people who experience suicidal thoughts also struggle with a mood disorder or substance abuse problem. If you think you may have one of these conditions, there are many places to seek help. For conditions such as PTSD, depression, or substance abuse, helpful treatments include medication from a primary care physician or psychiatrist, and therapy from a mental health provider such as a psychologist. To locate a mental health provider near you, call your doctor's office or ask a friend for a recommendation. The following link may also be a helpful way to locate a mental health professional http://www.mentalhealth.samhsa.gov/databases/. If you work for a large company or organization, call the human resources office to find out if they provide mental health services or make referrals. If you are ever considering suicide and feel unsafe, you may call the following hotline (available 24 hours a day) to speak with someone who can help: 1-800-273-TALK (1-800-273-8255) (en Español 1-888-628-9454).

If you do not struggle with a psychiatric illness, you may need to learn additional coping strategies for high levels of stress. There are many therapeutic treatments that could be helpful in this situation. Consider using one of the methods mentioned above to locate a mental health professional near you.

Someone I know is suicidal

It is likely that sometime during your life you will be exposed to a family member, peer, or coworker who is feeling suicidal. When someone discloses information about feeling suicidal, the information can be overwhelming, anxiety provoking, and frightening. This is particularly true if the disclosure is made in confidence and you feel pressure not to share the information with others. If someone you know is thinking about suicide, the issue should be taken very seriously. Individuals who contemplate suicide may not necessarily take action, but evaluating the risk can be complicated and should be done by a qualified mental health professional.

Helping a suicidal individual can be a difficult process. The person’s age will influence your first course of action. If your acquaintance is an adult, try to be supportive and listen to his or her concerns. Next, encourage that person to seek treatment immediately. Help the person with this process by remaining calm and providing information about mental health options in the area. Call 1-800-273-TALK (1-800-273-8255) or visit http://www.mentalhealth.samhsa.gov/databases/ to obtain referral information.

Often the most difficult part of obtaining treatment is the initial call to a mental health professional. It is usually easier for a suicidal individual to accept professional help if they have assistance with this part of the process. The decision to seek treatment is typically voluntary for adults. Their ability to maintain safety will determine the treatment options. Options include outpatient therapy, medication management, and inpatient treatment. Inpatient hospital visits are typically only prescribed when an individual is no longer safe without supervision. Sometimes involuntary hospital admission is necessary. However, because of federal laws protecting adult civil rights, this course of action in uncommon. Involuntary admission only occurs when an individual demonstrates unsafe behavior. If you feel that your acquaintance may hurt him- or herself or others, contact your local police department for assistance.

If the person with suicidal thoughts is a minor (under the age of 18), it is important to contact the minor’s parent or legal guardian. If the caregiver is unwilling or unable to take action, contact a mental health professional or law enforcement agent for assistance. United States federal law states that individuals under the age of 18 are not able to make mental health treatment decisions. Therefore, it is important that responsible adults see that minors receive the appropriate services. Treatment options for children and adolescents are similar to those outlined for adults. Unlike adults, however, minors may receive inpatient hospitalization without their consent if it is deemed necessary by their parents or the legal system.

While helping a suicidal person can be a difficult process, remember that the assistance you provide could save someone’s life.

Someone I know has committed suicide

It is always difficult to cope when an acquaintance commits suicide. Overcoming the suicide will be particularly challenging if you were emotionally close to the victim, if you witnessed the event, or if you have a prior history of psychiatric illness. Additional factors that complicate the grieving process include low socioeconomic status and low social support. Grieving the loss of a loved one is a natural process. It may take several months to feel “normal” again after your acquaintance commits suicide. Due to the traumatic nature of suicide, you may experience traumatic grief as part of the healing process. If you experience pronounced levels of grief several months after the suicide, contact a mental health professional for assistance. Lastly, many people experience intense guilt following the suicide of an acquaintance. This feeling is often related to thoughts about being unable to prevent the suicide. Suicide is never your fault. It is a complicated and difficult phenomenon to understand, with many contributing factors. To gain a better understanding of suicide or the grieving process, consider finding a mental health provider at http://www.mentalhealth.samhsa.gov/databases/.

References

Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide risk and coping styles in posttraumatic stress disorder patients. Psychotherapy and Psychosomatics, 68(2), 76–81.

Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who discovers or witnesses suicide? Psychological Reports, 42(3, Pt 1), 759–764.

Barraclough, B., & Hughes, J. (1987). Suicide: Clinical and epidemiological studies. New York, NY: Croom Helm.

Ben-Ya’acov, Y., & Amir, M. (2004). Posttraumatic symptoms and suicide risk. Personality and Individual Differences, 36, 1257–1264.

Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., et al. (1993a). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32(3), 521–529.

Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers, J., Allman, C., et al. (1993b). Adolescent witnesses to a peer suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32(6), 1184–1188.

Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R., et al. (1995). Posttraumatic stress disorder in peers of adolescent suicide victims: Predisposing factors and phenomenology. Journal of the American Academy of Child and Adolescent Psychiatry, 34(2), 209–-215.

Bullman, T. A., & Kang, H. K. (1995). A study of suicide among Vietnam veterans. Federal Practitioner, 12(3), 9–13.

Conwell, Y., Duberstein, P. R., Cox, C., Herrmann, J. H., Forbes, N. T., Caine, E. D. (1996). Relationship of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. American Journal of Psychiatry, 153(8), 1001–1008.

Dyregrov, K., Nordanger, D., & Dyregrov, A. (2003). Predictors of psychosocial distress after suicide, SIDS and accidents. Death Studies, 27(2), 143–165.

Fawcett, J. (1990). Targeting treatment in patients with mixed symptoms of anxiety and depression. Journal of Clinical Psychiatry, 51(11), 40–43.

Fontana, A., & Rosenheck, R. (1995). Attempted suicide among Vietnam veterans: A model of etiology in a community sample. American Journal of Psychiatry, 152(1), 102–109.

Gould, M., Jamieson, P., & Romer, D. (2003). Media contagion and suicide among the young. American Behavioral Scientist, 46(9), 1269–1284.

Gould, M. S. (2001). Suicide and the media. In H. Hendin & J. J. Mann (Eds.), The clinical science of suicide prevention. Annals of the New York Academy of Sciences, vol. 932 (pp. 200–224). New York, NY: New York Academy of Sciences.

Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry, 148(5), 586–591.

Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous & Mental Disease, 189(3), 162–167.

Mann, J. J., Waternaux, C., Haas, G. L., & Malone, K. M. (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156(2), 181–189.

Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., & Brent, D. A. (2004). Traumatic grief among adolescents exposed to a peer's suicide. American Journal of Psychiatry, 161(8), 1411–1416.

Murphy, S. A., Johnson, L. C., Wu, L., Fan, J. J., & Lohan, J. (2003). Bereaved parents' outcomes 4 to 60 months after their children's deaths by accident, suicide, or homicide: A comparative study demonstrating differences. Death Studies, 27(1), 29–61.

Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F. I., Maciejewsk, P. K., Davidson, J. R., et al. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 174, 67–73.

Qin, P., Agerbo, E., & Mortensen, P. B. (2002). Suicide risk in relation to family history of completed suicide and psychiatric disorders: A nested case-control study based on longitudinal registers. Lancet, 360(9340), 1126–1130.

Robison, B. K. (2002). Suicide risk in Vietnam veterans with posttraumatic stress disorder. Unpublished Doctoral Dissertation, Pepperdine University.

Runeson, B., & Åsberg, M. (2003). Family history of suicide among suicide victims. American Journal of Psychiatry, 160(8), 1525–1526.

Shaffer, D., Gould, M. S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., et al. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53(4), 339–348.

Soloff, P. H., Lynch, K. G., Kelly, T. M., Malone, K. M., & Mann, J. J. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: A comparative study. American Journal of Psychiatry, 157(4), 601–608.

Stroebe, W., & Stroebe, M. (1987). Bereavement as a stressful life event: A paradigm for research on the stress-health relationship? In G. R. Semin (Ed.), Issues in contemporary German social psychology: History, theories and application (pp. 258–272). Thousand Oaks, CA: Sage Publications, Inc.

Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic stress disorder as risk factors for suicide attempts in a sample of low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59–72.