Background
Suicide remains a serious public health problem in the United States, with peer-reviewed data showing long-term increases in suicide rates over recent decades. For example, US age-adjusted suicide rates rose by approximately 35.6% between 2001 and 2021, underscoring a persistent upward trend in suicide mortality over time. [1]
Suicidal behavior, including ideation and attempts, is prevalent across the general population. Epidemiologic research suggests that between 2.4% and 5.3% of adults report at least one lifetime suicide attempt, a figure that includes individuals who otherwise appear psychiatrically healthy, highlighting the widespread occurrence of serious risk behaviors that clinicians encounter in practice. [2]
Suicide affects individuals across the lifespan, including adolescents, where analyses have demonstrated persistent concerns regarding increasing rates and method disparities among youth subgroups. [3]
Globally, suicide continues to exact a substantial toll, and many deaths are preventable through early recognition, assessment, and intervention by clinicians.
Terminology and definitions
Table 1 below defines commonly used terms related to suicidal thoughts and behaviors.
Table 1. Key terminology related to suicidal thoughts and behaviors. (Open Table in a new window)
| Term | Definition |
|---|---|
| Suicidal ideation | Thoughts of death or self-harm. May be passive (eg, wishing not to wake up) or active (thinking about killing oneself). |
| Suicidal intent | Desire or expectation that an act of self-harm will result in death. |
| Suicide attempt | Nonfatal, self-directed behavior with at least some intent to die. |
| Aborted attempt | A suicide attempt that is stopped by the individual before the behavior occurs. |
| Interrupted attempt | A suicide attempt that is stopped by another person or external circumstance. |
| Preparatory behavior | Actions suggesting imminent risk (eg, acquiring a firearm, stockpiling medications, writing a suicide note, giving away possessions). |
| Nonsuicidal self-injury (NSSI) | Intentional self-inflicted injury (eg, cutting, burning) without intent to die. |
| Self-harm | Umbrella term for self-inflicted injury that may include NSSI or suicidal behavior, depending on intent. |
| Suicide plan | A specific method or strategy for attempting suicide, including timing, location, and access to means. |
| Suicide gesture | Historically used to describe self-harm perceived as low lethality; the term is considered imprecise and potentially dismissive and should generally be avoided in clinical documentation. |
Epidemiology
Occurrence in the United States
Suicide is a critical contributor to preventable mortality in the United States, with age-adjusted rates reaching a contemporary peak of approximately 14.5 per 100,000 individuals. In 2023, suicide was the 11th leading cause of death in the United States, with more than 49,000 deaths reported (approximately one death every 11 minutes). [4] While the last two decades show a persistent upward trend, current data suggest a relative stabilization at these record highs. Clinicians should note that while suicidal ideation is common, the transition to lethal action is often driven by access to high-lethality means. Firearms are now involved in more than half of all suicide deaths nationwide. Notably, a 2025 systematic analysis for the Global Burden of Disease (GBD) identified the United States as having the highest age-standardized rate of firearm-related suicides among all 204 countries and territories analyzed. [5]
The distribution of suicide risk across the lifespan is distinct. Although suicide is the second leading cause of death for adolescents and young adults (ages 10–34), the highest absolute mortality rates occur among older adults, particularly males aged ≥ 75 years. [6] Suicide mortality remains substantially higher among males, who account for nearly 80% of suicide deaths. [4] Middle-aged adults (ages 35–64) continue to represent the largest volume of total deaths, frequently involving a complex interplay of chronic pain, substance use disorders, and socioeconomic stressors.
International occurrence
Globally, suicide accounts for an estimated 746,000 deaths annually, with the vast majority (~73%) occurring in low- and middle-income countries (LMICs). [5] While the US clinical focus is often on firearms, the global burden is heavily influenced by the ingestion of pesticides and medications, reflecting regional availability of lethal means. Across regions, the "treatment gap" remains a primary barrier; most individuals who die by suicide do not have an active mental health provider at the time of death, emphasizing the need for universal screening in primary and emergency care settings.
Demographic patterns
Epidemiological data continues to demonstrate a significant "gender paradox": men die by suicide at nearly four times the rate of women, whereas women present more frequently with non-fatal self-harm and suicide attempts. Racial and ethnic disparities remain stark. American Indian and Alaska Native populations experience the highest burden of suicide, followed by non-Hispanic White individuals. [7] However, of urgent clinical concern is the accelerating rate of suicide among Black and Hispanic youth, a trend that, in several analyses, has outpaced other demographics over the last decade. [8]
Risk Factors
Suicide risk is influenced by a complex combination of psychiatric, medical, psychosocial, and environmental factors. Although many individuals experience suicidal ideation at some point, progression to suicidal behavior is more likely when multiple risk factors converge, particularly in the presence of impaired judgment, substance use, acute crisis, or access to high-lethality means.
Psychiatric illness
Psychiatric disorders are among the strongest predictors of suicidal behavior. Major depressive disorder, bipolar disorder, schizophrenia and related psychotic disorders, posttraumatic stress disorder (PTSD), substance use disorders, and personality disorders are consistently associated with elevated suicide risk. Psychiatric hospitalization and recent discharge from inpatient psychiatric care represent particularly high-risk periods. [9, 10]
Depression is strongly associated with suicidal ideation and suicide attempts, particularly when accompanied by hopelessness, social withdrawal, or comorbid anxiety. Suicide risk may increase during periods of clinical transition, including partial symptomatic improvement, when energy and motivation return before mood has fully stabilized.
Bipolar disorder is associated with a high lifetime risk of suicidal behavior, particularly in individuals with early onset, prominent depressive episodes, mixed features, comorbid anxiety, or substance use. [11, 12, 13] Schizophrenia is also associated with elevated suicide risk, particularly in patients with comorbid depression, substance use, command hallucinations, or insight into functional decline. [14] Clozapine remains the only medication approved by the US FDA for reducing suicidal behavior in patients with schizophrenia or schizoaffective disorder. [15, 16]
Obsessive-compulsive disorder and panic disorder may also be associated with suicidality, particularly when comorbid depression, substance use, or personality pathology is present. [17, 18, 19] PTSD, especially in veterans and individuals with a history of trauma exposure, is associated with increased suicidal ideation and attempts. [20, 21, 22, 23]
Substance use disorders
Alcohol and drug use are major contributors to suicide risk. Intoxication may increase impulsivity, reduce inhibition, and worsen depressive symptoms, thereby increasing the likelihood that suicidal ideation progresses to an attempt. Withdrawal states and chronic substance use can also contribute to suicidality through worsening mood instability, impaired judgment, and social deterioration. [24] Co-occurring substance use disorder and depression markedly increases suicide risk.
Prior suicidal behavior and self-harm
A history of suicide attempt is one of the strongest predictors of future suicide attempts and death by suicide. The presence of recurrent self-harm, escalating severity of attempts, or increasing lethality of method is particularly concerning. Family history of suicide or suicidal behavior is also a significant risk factor and may reflect both genetic vulnerability and environmental exposure. [25]
Access to lethal means
Access to firearms is strongly associated with suicide death, reflecting the high lethality of this method. Firearm access increases the likelihood that an impulsive suicidal crisis results in fatality. Clinicians should routinely assess access to firearms and other lethal means as part of suicide risk evaluation. [26, 27, 28, 29]
Medical illness and chronic pain
Chronic medical illness and disability are associated with increased suicide risk, particularly when accompanied by functional decline, loss of independence, or chronic pain. Elevated suicide risk has been reported in individuals with cancer, end-stage renal disease, chronic obstructive pulmonary disease, HIV infection, neurologic disorders, and other debilitating conditions. [30, 31, 32, 33] Chronic pain syndromes may further increase suicide risk, particularly in the setting of comorbid depression, opioid use disorder, or social isolation.
Traumatic brain injury has also been associated with increased risk of suicidal behavior, particularly among individuals with repeated injuries and comorbid psychiatric illness. [34, 35, 36]
Psychosocial stressors and adverse life events
Acute psychosocial stressors commonly precede suicidal behavior. Broader structural factors (eg, poverty, housing insecurity, discrimination, and limited access to health care) may also contribute to suicide risk at the population level. Relationship loss, divorce, job loss, legal problems, financial instability, bereavement, and social isolation are frequently reported precipitants. [37] Trauma exposure, including physical or sexual abuse, is associated with increased lifetime risk of suicidal ideation and attempts. [38, 39, 40]
Bullying victimization has also been associated with self-harm and suicide attempts, particularly among adolescents. [41, 42, 43] Exposure to suicide within peer groups or communities may increase risk through contagion effects. [44, 45]
High-risk transition periods
Certain clinical and situational transitions are associated with increased suicide risk. These include recent discharge from psychiatric hospitalization, incarceration or early confinement, and separation from military service. [46, 47, 48, 49, 50] These periods may involve abrupt loss of structure and support, increased stress, and limited access to mental health services.
Medications
Several medication classes have been associated with suicidal ideation or behavior, leading to FDA warnings for certain antidepressants and anticonvulsants. [51, 52] Although these warnings highlight the importance of monitoring, untreated psychiatric illness remains a major driver of suicide risk. Clinicians should closely monitor patients after initiation or dose changes of psychotropic medications, particularly in younger populations and in individuals with worsening mood symptoms, agitation, or emerging suicidal ideation.
Pathophysiology
Suicidal behavior is multifactorial and reflects the interaction of psychiatric illness, psychosocial stressors, neurobiologic vulnerability, and access to lethal means. Although suicide is not attributable to a single mechanism, converging evidence suggests that dysregulation of mood, stress response, and impulse control pathways contribute to increased suicide risk.
Neurobiologic models have historically emphasized altered serotonergic function, which may contribute to impaired behavioral inhibition, aggression, and impulsivity. Stress-related dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis has also been implicated, particularly in individuals with major depressive disorder, trauma-related disorders, and chronic stress exposure. These biologic vulnerabilities may lower the threshold for suicidal behavior in the setting of acute psychosocial crises or substance intoxication. [53, 54]
Emerging research has also suggested possible associations between neuroinflammation and suicidality. Elevated inflammatory markers have been observed in some patients with major depressive disorder and suicidal ideation or attempts, although causality remains unclear and findings are not currently used in routine clinical risk assessment. [55] Overall, suicidal behavior is best conceptualized as the downstream clinical expression of intersecting psychiatric, biologic, and environmental risk factors.
Prognosis
The prognosis of suicidal behavior depends on the underlying psychiatric illness, presence of substance use disorders, access to lethal means, and the availability of timely intervention. A prior suicide attempt remains one of the strongest predictors of future suicide attempts and death by suicide.
Short-term suicide risk is especially elevated during major clinical and situational transitions. Recent discharge from psychiatric hospitalization is a well-recognized period of increased vulnerability, and careful follow-up planning is essential during the weeks immediately after discharge. [10]
Prognosis is also influenced by the severity and chronicity of psychiatric illness. Individuals with major depressive disorder, bipolar disorder, schizophrenia, and posttraumatic stress disorder remain at elevated risk, particularly when comorbid substance use, hopelessness, psychosis, or impaired judgment is present. [13]
Because suicidal crises may be episodic and impulsive, prognosis is strongly affected by access to lethal means, particularly firearms. Restriction of lethal means and active safety planning are key components of reducing near-term risk and improving outcomes. [26, 29]
Overall, suicidal behavior is not inevitably progressive, and many individuals recover with appropriate treatment and support. Early recognition, risk assessment, and structured follow-up remain central to improving long-term outcomes.
Patient Education
Patient and family education should emphasize that suicidal ideation and suicidal behavior represent a medical emergency requiring prompt evaluation. Clinicians should counsel patients and caregivers on warning signs, safety planning, and restricting access to lethal means (eg, firearms, medications). [56]
Patients and families should be provided with crisis resources. In the United States, the 988 Suicide & Crisis Lifeline provides 24/7 confidential support via phone, text, or chat and should be included in patient counseling and discharge planning. [57]
Family members and caregivers should also be educated on how to respond if suicide risk escalates, including seeking emergency services when imminent danger is suspected. [56]
Tables
| Term | Definition |
|---|---|
| Suicidal ideation | Thoughts of death or self-harm. May be passive (eg, wishing not to wake up) or active (thinking about killing oneself). |
| Suicidal intent | Desire or expectation that an act of self-harm will result in death. |
| Suicide attempt | Nonfatal, self-directed behavior with at least some intent to die. |
| Aborted attempt | A suicide attempt that is stopped by the individual before the behavior occurs. |
| Interrupted attempt | A suicide attempt that is stopped by another person or external circumstance. |
| Preparatory behavior | Actions suggesting imminent risk (eg, acquiring a firearm, stockpiling medications, writing a suicide note, giving away possessions). |
| Nonsuicidal self-injury (NSSI) | Intentional self-inflicted injury (eg, cutting, burning) without intent to die. |
| Self-harm | Umbrella term for self-inflicted injury that may include NSSI or suicidal behavior, depending on intent. |
| Suicide plan | A specific method or strategy for attempting suicide, including timing, location, and access to means. |
| Suicide gesture | Historically used to describe self-harm perceived as low lethality; the term is considered imprecise and potentially dismissive and should generally be avoided in clinical documentation. |
