Symptoms and Danger Signs

• Ideation (thinking, talking or wishing about suicide)

• Substance use or abuse (increased use or change in substance)

• Purposelessness (no sense of purpose or belonging)

• Anger

• Trapped (feeling like there is no way out)

• Hopelessness (there is nothing to live for, no hope or optimism)

• Withdrawal (from family, friends, work, school, activities, hobbies)

• Anxiety (restlessness, irritability, agitation)

• Recklessness (high risk-taking behavior)

• Mood disturbance (dramatic changes in mood)

Additional Warning Signs of Suicide

Talking about suicide.

• Looking for ways to die (internet searches for how to commit suicide, looking for guns, pills, etc.)

• Statements about hopelessness, helplessness, or worthlessness.

• Preoccupation with death.

• Suddenly happier, calmer.

• Loss of interest in things one cares about

• Visiting or calling people one cares about.

• Making arrangements; setting one's affairs in order.

• Giving things away, such as prized possessions.

A suicidal person urgently needs to see a doctor or mental health professional. In an emergency, call the National Suicide Prevention Lifeline 1-800-273-TALK

What do I do now?

Some survivors struggle with what to tell other people. Although you should make whatever decision feels right to you, most survivors have found it best to simply acknowledge that their loved one died by suicide. You may find that it helps to reach out to family and friends. Because some people may not know what to say, you may need to take the initiative to talk about the suicide, share your feelings, and ask for their help. Even though it may seem difficult, maintaining contact with other people is especially important during the stress-filled months after a loved one's suicide. Keep in mind that each person grieves in his or her own way. Some people visit the cemetery weekly; others find it too painful to go at all. Each person also grieves at his or her own pace; there is no set rhythm or timeline for healing. Anniversaries, birthdays, and holidays may be especially difficult, so you might want to think about whether to continue old traditions or create some new ones. You may also experience unexpected waves of sadness; these are a normal part of the grieving process.

Children experience many of the feelings of adult grief, and are particularly vulnerable to feeling abandoned and guilty.Reassure them that the death was not their fault. Listen to their questions, and try to offer honest, straightforward, age-appropriate answers. Some survivors find comfort in community, religious, or spiritual activities, including talking to a trusted member of the clergy.

Be kind to yourself. When you feel ready, begin to go on with your life. Eventually starting to enjoy life again is not a betrayal of your loved one, but rather a sign that you've begun to heal.

Suicide claims the lives of over 31,000 people each year, more than homicide or HIV/AIDS. Nevertheless, suicide is a topic that is infrequently discussed, mostly due to the stigma that surrounds it. Research has shown that more than 90 percent of people who die by suicide have depression or another diagnosable mental or substance abuse disorder.

It is important to report suicide in a responsible manner. Romanticizing or idealizing the victim has been shown to have serious detrimental effects - in the worst case, leading to copycat suicides.

When reporting on a suicide, it is best not to include personal details regarding the victim, the method used, or a rationale for the death. It is helpful to include the warning/signs and risk factors for suicide, to emphasize suicide prevention and to explicitly recommend treatment for depression and other mental illnesses.

For more information on responsible reporting of suicide, view the guidelines below

Reporting on Suicide:
Recommendations for the Media
American Foundation for Suicide Prevention
American Association of Suicidology
Annenberg Public Policy Center
Suicide Contagion is Real

...between 1984 and 1987, journalists in Vienna covered the deaths of individuals who jumped in front of trains in the subway system. The coverage was extensive and dramatic. In 1987, a campaign alerted reporters to the possible negative effects of such reporting, and suggested alternate strategies for coverage. In the first six months after the campaign began, subway suicides and non-fatal attempts dropped by more than eighty percent. The total number of suicides in Vienna declined as well.1,2

Research finds an increase in suicide by readers or viewers when:

The number of stories about individual suicides increases 3,4
A particular death is reported at length or in many stories 3,5
The story of an individual death by suicide is placed on the front page or at the beginning of a broadcast 3,4
The headlines about specific suicide deaths are dramatic3 (A recent example: "Boy, 10, Kills Himself Over Poor Grades")

Recommendations

The media can play a powerful role in educating the public about suicide prevention. Stories about suicide can inform readers and viewers about the likely causes of suicide, its warning signs, trends in suicide rates, and recent treatment advances. They can also highlight opportunities to prevent suicide. Media stories about individual deaths by suicide may be newsworthy and need to be covered, but they also have the potential to do harm. Implementation of recommendations for media coverage of suicide has been shown to decrease suicide rates.1,2

Certain ways of describing suicide in the news contribute to what behavioral scientists call "suicide contagion" or "copycat" suicides.7,9

Research suggests that inadvertently romanticizing suicide or idealizing those who take their own lives by portraying suicideas a heroic or romantic act may encourage others to identify with the victim.6

Exposure to suicide method through media reports can encourage vulnerable individuals to imitate it.10 Clinicians believe the danger is even greater if there is a detailed description of the method. Research indicates that detailed descriptions or pictures of the location or site of a suicide encourage imitation.1

Presenting suicide as the inexplicable act of an otherwise healthy or high-achieving person may encourage identification with the victim.6

Suicide and Mental Illness

Did you know?

Over 90 percent of suicide victims have a significant psychiatric illness at the time of their death. These are often undiagnosed, untreated, or both. Mood disorders and substance abuse are the two most common.11-15
When both mood disorders and substance abuse are present, the risk for suicide is much greater, particularly for adolescents and young adults.14,15
Research has shown that when open aggression, anxiety or agitation is present in individuals who are depressed, the risk for suicide increases significantly.16-18

The cause of an individual suicide is invariably more complicated than a recent painful event such as the break-up of a relationship or the loss of a job. An individual suicide cannot be adequately explained as the understandable response to an individual's stressful occupation, or an individual's membership in a group encountering discrimination. Social conditions alone do not explain a suicide.19-20 People who appear to become suicidal in response to such events, or in response to a physical illness, generally have significant underlying mental problems, though they may be well-hidden.12

Questions to ask:

Had the victim ever received treatment for depression or any other mental disorder?
Did the victim have a problem with substance abuse?

Angles to pursue:

Conveying that effective treatments for most of these conditions are available (but underutilized) may encourage those with such problems to seek help.

Acknowledging the deceased person's problems and struggles as well as the positive aspects of his/her life or character contributes to a more balanced picture. Interviewing Surviving Relatives and Friends Research shows that, during the period immediately after a death by suicide, grieving family members or friends have difficulty understanding what happened.

Responses may be extreme, problems may be minimized, and motives may be complicated.21 Studies of suicide based on in-depth interviews with those close to the victim indicate that, in their first, shocked reaction, friends and family members may find a loved one's death by suicide inexplicable or they may deny that there were warning signs.22,23 Accounts based on these initial reactions are often unreliable.

Angles to Pursue

Thorough investigation generally reveals underlying problems unrecognized even by close friends and family members. Most victims do however give warning signs of their risk for suicide (see Resources).

Some informants are inclined to suggest that a particular individual, for instance a family member, a school, or a health service provider, in some way played a role in the victim's death by suicide. Thorough investigation almost always finds multiple causes for suicide and fails to corroborate a simple attribution of responsibility.

Concerns

Dramatizing the impact of suicide through descriptions and pictures of grieving relatives, teachers or classmates or community expressions of grief may encourage potential victims to see suicide as a way of getting attention or as a form of retaliation against others.

Using adolescents on TV or in print media to tell the stories of their suicide attempts may be harmful to the adolescents themselves or may encourage other vulnerable young people to seek attention in this way.

Language

Referring to a "rise" in suicide rates is usually more accurate than calling such a rise an "epidemic," which implies a more dramatic and sudden increase than what we generally find in suicide rates. Research has shown that the use in headlines of the word suicide or referring to the cause of death as self-inflicted increases the likelihood of contagion.3

Recommendations for language

Whenever possible, it is preferable to avoid referring to suicide in the headline. Unless the suicide death took place in public, the cause of death should be reported in the body of the story and not in the headline.

In deaths that will be covered nationally, such as of celebrities, or those apt to be covered locally, such as persons living in small towns, consider phrasing for headlines such as: "Marilyn Monroe dead at 36," or "John Smith dead at 48." Consideration of how they died could be reported in the body of the article.

In the body of the story, it is preferable to describe the deceased as "having died by suicide," rather than as "a suicide," or having "committed suicide." The latter two expressions reduce the person to the mode of death, or connote criminal or sinful behavior.

Contrasting "suicide deaths" with "non-fatal attempts" is preferable to using terms such as "successful," "unsuccessful" or "failed."

Special Situations

Celebrity Deaths
Celebrity deaths by suicide are more likely than non-celebrity deaths to produce imitation.24Although suicides by celebrities will receive prominent coverage, it is important not to let the glamour of the individual obscure any mental health problems or use of drugs.

Homicide-Suicides
In covering murder-suicides be aware that the tragedy of the homicide can mask the suicidal aspect of the act. Feelings of depression and hopelessness present before the homicide and suicide are often the impetus for both.25,26

Suicide Pacts
Suicide pacts are mutual arrangements between two people who kill themselves at the same time, and are rare. They are not simply the act of loving individuals who do not wish to be separated. Research shows that most pacts involve an individual who is coercive and another who is extremely dependent.27

MYTH: People who talk about suicide are just trying to get attention.
FACT: People who die by suicide usually talk about it first. They are in pain and oftentimes reach out for help because they do not know what to do and have lost hope. Always take time to talk about suicide seriously. Always.

MYTH: People who talk about wanting to die by suicide do not try to kill themselves.
FACT: People who talk about wanting to die by suicide oftentimes kill themselves.

MYTH: Suicide always occurs without any warning signs.
FACT: There are almost always warning signs.

MYTH: Once people decide to die by suicide, there is nothing you can do to stop them.
FACT: Suicide can be prevented. Most people who are suicidal do not want to die; they just want to stop their pain.

MYTH: Suicide only strikes people of a certain gender, race, financial status, age, etc.
FACT: Suicide can strike anyone.

MYTH: People who attempt suicide and survive will not attempt suicide again
FACT: People who attempt suicide and survive will oftentimes make additional attempts.

MYTH: People who attempt suicide are weak.
FACT: No, no, no. They are in pain and probably have a chemical imbalance in their brain. Many people who are very "strong" die by suicide.

MYTH: People who talk about suicide are trying to manipulate others.
FACT: No. People who talk about suicide are in pain and need help. And telling them that they "just want something" or "are trying to manipulate" is both insensitive and ignorant. People often talk about suicide before dying by suicide. Always take talk about suicide seriously. Always.

MYTH: When people become suicidal, they will always be suicidal.
FACT: Most people are suicidal for a limited period of time. However, suicidal feelings can recur.

MYTH: People who are suicidal definitely want to die.
FACT: The vast majority of people who are suicidal do not want to die. They are in pain, and they want to stop the pain.

MYTH: You should never ask people who are suicidal person if they are thinking about suicide or if they have thought about a method, because just talking about it will
give them the idea.

FACT: Asking people if they are thinking about suicide does not give them the idea for suicide. And it is important to talk about suicide with people who are suicidal because you will learn more about their mindset and intentions, and allow them to diffuse some of the tension that is causing their suicidal feelings.

MYTH: When people who are suicidal feel better, they are no longer suicidal.
FACT: Sometimes suicidal people feel better because they have decided to die by suicide, and may feel a sense of relief that the pain will soon be over.

MYTH: Young people never think about suicide, they have their entire life ahead of them.
FACT: Suicide is the third leading cause of death for young people aged 15-24. Sometimes children under 10 die by suicide.

MYTH: There is little correlation between alcohol or drug abuse and suicide.
FACT: Oftentimes people who die by suicide are under the influence of alcohol or drugs.

MYTH: People who are suicidal do not seek help
FACT: Many people who are suicidal reach out for help.

-If you are suicidal, immediate action is required-

Suicide is a major public health problem:
More than 34,500 Americans died by suicide in 2007 (AAS)
There is 1 suicide every 15.2 minutes (AAS)
24% of the general population has considered suicide at some time in his/her life (Linehan et al., 1982)

Suicide is the:
11th leading cause of death overall in America (CDC)
3rd leading cause of death for young Americans between the ages of 10-24 (CDC)
2nd leading cause of death for American college-aged students (Kochanek et al., 2002)
There are an estimated 864,950 attempts per year in the U.S. (SAMHSA)
13.8 million Americans will attempt suicide in their lifetime (Kessler, et al., 1999)
Each suicide produces at least six, and as many as hundreds of “survivors,” or people left behind to grieve. Based on the 766,042 suicides from 1982 through 2007, it can be estimated that the number of survivors in the U.S. is 4.6 million. (AAS)

Suicide is an often ignored and stigmatized topic:
For every two people who die from homicides, three people die of suicide (Kochanek et al., 2002)
There are more suicides globally than deaths from war and violence combined (WHO)
Approximately twice as many Americans die by suicides than from HIV/AIDS (CDC)
Less than half of adults with serious mental illness received treatment or counseling in the past year (SAMHSA)

Suicides can be prevented:
More than 60% of adolescents and 90% of adults who die by suicide have depression or another diagnosable mental or substance abuse disorder (Brent et al., 1999; Cavanaugh et al., 2003; Conner et al., 2007; Conwell et al., 1996; Fortune et al., 2007; Hawton et al., 2002)
In a national poll, 78% of Americans think that many suicides are preventable with appropriate research, interventions and services (Research America, 2006)
86% of Americans surveyed think it is important to invest in the prevention of suicide (Research America, 2006)

Risk and protective factors can vary according to age, gender, ethnic group or occupation, and can vary over time. Some examples are:

20% of all suicide deaths occur among veterans (NVDRS)
More women attempt suicide, more men die by suicide (CDC)
79.4% of completed suicides are men (CDC)
14.5% of students, grade 9-12, seriously considered suicide in the previous 12 months (18.7% of females and 10.3% of males). (CDC)
According to several nationally representative studies, in any given year, about 5% to 7% of adults have a serious mental illness. A similar percentage of children (about 5% to 9%) have a serious emotional disturbance (Office of the Surgeon General, 2001; HHS, 2002; Kessler et al., 2001)
Elderly comprise 12.6% of the population yet account for 15.7% of suicides (AAS)
Among industrialized countries, most report that suicide rates rise progressively with age, with the highest rates occurring for men age 75 and older (Joiner, 2005; Pearson, 2002).
In general, suicide rates increase with age with rates among people aged 75 years and older approximately three times those among people aged 15-24 years (CDC).
Among older adults, older white males have the highest rates of suicide (Conwell & Duberstein, 2001; Conwell, Duberstein, & Caine, 2002; Heisel, 2006; Meehan, Saltzman, & Sattin 1991; Pearson, 2002).

In addition to the tragedy of lost lives, mental illnesses come with a devastatingly high financial cost. In the U.S., the annual economic, indirect cost of mental illnesses is estimated to be $79 billion: $63 billion in lost productivity, $12 billion in mortality costs, and $4 billion in productivity losses for incarcerated individuals and for the time of those who provide family care (HHS, 2002; Moscicki, 2001)

Suicide claims the lives of over 31,000 people each year, more than homicide or HIV/AIDS. Nevertheless, suicide is a topic that is infrequently discussed, mostly due to the stigma that surrounds it. Research has shown that more than 90 percent of people who die by suicide have depression or another diagnosable mental or substance abuse disorder. It is important to report suicide in a responsible manner. Romanticizing or idealizing the victim has been shown to have serious detrimental effects - in the worst case, leading to copycat suicides. When reporting on a suicide, it is best not to include personal details regarding the victim, the method used, or a rationale for the death. It is helpful to include the warning/signs and risk factors for suicide, to emphasize suicide prevention and to explicitly recommend treatment for depression and other mental illnesses.
For more information on responsible reporting of suicide, view the guidelines below reporting on Suicide Recommendations for the Media:

American Foundation for Suicide Prevention

American Association of Suicidology

Annenberg Public Policy Center

Suicide Contagion is Real
...between 1984 and 1987, journalists in Vienna covered the deaths of individuals who jumped in front of trains in the subway system. The coverage was extensive and dramatic. In 1987, a campaign alerted reporters to the possible negative effects of such reporting, and suggested alternate strategies for coverage. In the first six months after the campaign began, subway suicides and non-fatal attempts dropped by more than eighty percent. The total number of suicides in Vienna declined as well.1,2

Research finds an increase in suicide by readers or viewers when:

The number of stories about individual suicides increases 3,4
A particular death is reported at length or in many stories 3,5
The story of an individual death by suicide is placed on the front page or at the beginning of a broadcast 3,4
The headlines about specific suicide deaths are dramatic3 (A recent example: "Boy, 10, Kills Himself Over Poor Grades")

Recommendations
The media can play a powerful role in educating the public about suicide prevention. Stories about suicide can inform readers and viewers about the likely causes of suicide, its warning signs, trends in suicide rates, and recent treatment advances. They can also highlight opportunities to prevent suicide. Media stories about individual deaths by suicide may be newsworthy and need to be covered, but they also have the potential to do harm. Implementation of recommendations for media coverage of suicide has been shown to decrease suicide rates.1,2
Certain ways of describing suicide in the news contribute to what behavioral scientists call "suicide contagion" or "copycat" suicides.7,9
Research suggests that inadvertently romanticizing suicide or idealizing those who take their own lives by portraying suicideas a heroic or romantic act may encourage others to identify with the victim.6
Exposure to suicide method through media reports can encourage vulnerable individuals to imitate it.10 Clinicians believe the danger is even greater if there is a detailed description of the method. Research indicates that detailed descriptions or pictures of the location or site of a suicide encourage imitation.1
Presenting suicide as the inexplicable act of an otherwise healthy or high-achieving person may encourage identification with the victim.6

Suicide and Mental Illness

Did you know?

Over 90 percent of suicide victims have a significant psychiatric illness at the time of their death. These are often undiagnosed, untreated, or both. Mood disorders and substance abuse are the two most common.11-15
When both mood disorders and substance abuse are present, the risk for suicide is much greater, particularly for adolescents and young adults.14,15
Research has shown that when open aggression, anxiety or agitation is present in individuals who are depressed, the risk for suicide increases significantly.16-18

The cause of an individual suicide is invariably more complicated than a recent painful event such as the break-up of a relationship or the loss of a job. An individual suicide cannot be adequately explained as the understandable response to an individual's stressful occupation, or an individual's membership in a group encountering discrimination. Social conditions alone do not explain a suicide.19-20 People who appear to become suicidal in response to such events, or in response to a physical illness, generally have significant underlying mental problems, though they may be well-hidden.12

Questions to ask:
Had the victim ever received treatment for depression or any other mental disorder?
Did the victim have a problem with substance abuse?

Angles to pursue:
Conveying that effective treatments for most of these conditions are available (but underutilized) may encourage those with such problems to seek help.
Acknowledging the deceased person's problems and struggles as well as the positive aspects of his/her life or character contributes to a more balanced picture. Interviewing Surviving Relatives and Friends Research shows that, during the period immediately after a death by suicide, grieving family members or friends have difficulty understanding what happened.
Responses may be extreme, problems may be minimized, and motives may be complicated.21 Studies of suicide based on in-depth interviews with those close to the victim indicate that, in their first, shocked reaction, friends and family members may find a loved one's death by suicide inexplicable or they may deny that there were warning signs.22,23 Accounts based on these initial reactions are often unreliable.

Angles to Pursue

Thorough investigation generally reveals underlying problems unrecognized even by close friends and family members. Most victims do however give warning signs of their risk for suicide (see Resources).

Some informants are inclined to suggest that a particular individual, for instance a family member, a school, or a health service provider, in some way played a role in the victim's death by suicide. Thorough investigation almost always finds multiple causes for suicide and fails to corroborate a simple attribution of responsibility.

Concerns
Dramatizing the impact of suicide through descriptions and pictures of grieving relatives, teachers or classmates or community expressions of grief may encourage potential victims to see suicide as a way of getting attention or as a form of retaliation against others.
Using adolescents on TV or in print media to tell the stories of their suicide attempts may be harmful to the adolescents themselves or may encourage other vulnerable young people to seek attention in this way.

Language
Referring to a "rise" in suicide rates is usually more accurate than calling such a rise an "epidemic," which implies a more dramatic and sudden increase than what we generally find in suicide rates. Research has shown that the use in headlines of the word suicide or referring to the cause of death as self-inflicted increases the likelihood of contagion.3

Recommendations for language
Whenever possible, it is preferable to avoid referring to suicide in the headline. Unless the suicide death took place in public, the cause of death should be reported in the body of the story and not in the headline.
In deaths that will be covered nationally, such as of celebrities, or those apt to be covered locally, such as persons living in small towns, consider phrasing for headlines such as: "Marilyn Monroe dead at 36," or "John Smith dead at 48." Consideration of how they died could be reported in the body of the article.
In the body of the story, it is preferable to describe the deceased as "having died by suicide," rather than as "a suicide," or having "committed suicide." The latter two expressions reduce the person to the mode of death, or connote criminal or sinful behavior. Contrasting "suicide deaths" with "non-fatal attempts" is preferable to using terms such as "successful," "unsuccessful" or "failed."

Special Situations

Celebrity Deaths
Celebrity deaths by suicide are more likely than non-celebrity deaths to produce imitation.24Although suicides by celebrities will receive prominent coverage, it is important not to let the glamour of the individual obscure any mental health problems or use of drugs.

Homicide-Suicides
In covering murder-suicides be aware that the tragedy of the homicide can mask the suicidal aspect of the act. Feelings of depression and hopelessness present before the homicide and suicide are often the impetus for both.25,26

Suicide Pacts
Suicide pacts are mutual arrangements between two people who kill themselves at the same time, and are rare. They are not simply the act of loving individuals who do not wish to be separated. Research shows that most pacts involve an individual who is coercive and another who is extremely dependent.27

United States
Centers for Disease Control and Prevention - 800-311-3435
Substance Abuse and Mental Health
Services Administration - 800-487-4890
Office of the Surgeon General
National Strategy for Suicide Prevention
American Association of Suicidology - 202-237-2280
American Foundation for Suicide Prevention - 888-333-AFSP

International
Canterbury Suicide Project (New Zealand) - 64 3 372 0408
National Centre for Suicide Research and Prevention of Mental-Ill Health (Sweden)+46 852 48 7026
National Youth Suicide Prevention Project (Australia) - 61 9214 7888
Centre for Suicide Prevention - 403-245-3900
World Health Organization - +00 41 22 791 21 11
American Foundation for Suicide Prevention - 888-333-AFSP

References

1. Sonneck, G., Etzersdorfer, E., & Nagel-Kuess, S. (1994). Imitative suicide on the Viennese subway. Social Science and Medicine, 38, 453- 457.
2. Etzersdorfer, E., & Sonneck, G. (1998). Preventing suicide by influencing mass-media reporting. The Viennese experience 1980-1996. Archives of Suicide Research, 4, 67-74.
3. Phillips, D.P., Lesyna, K., & Paight, D.J. (1992). Suicide and the media. In R.W. Maris, A.L. Berman, J.T. Maltsberger et al. (Eds.), Assessment and prediction of suicide (pp. 499-519). New York: The Guilford Press.
4. Hassan, R. (1995). Effects of newspaper stories on the incidence of suicide in Australia: A research note. Australian and New Zealand Journal of Psychiatry, 29, 480-483.
5. Stack, S. (1991). Social correlates of suicide by age: Media impacts. In A. Leenaars (Ed.), Life span perspectives of suicide: Timelines in the suicide process (pp. 187-213). New York: Plenum Press.
6. Fekete, S., & A. Schmidtke. (1995) The impact of mass media reports on suicide and attitudes toward self-destruction: Previous studies and some new data from Hungary and Germany. In B. L. Mishara (Ed.), The impact of suicide. (pp. 142-155). New York: Springer.
7. Schmidtke, A., & Häfner, H. (1988). The Werther effect after television films: New evidence for an old hypothesis. Psychological Medicine 18, 665-676.
8. Gould, M.S., & Davidson, L. (1988). Suicide contagion among adolescents. In A.R. Stiffman, & R.A. Feldman (Eds.), Advances in adolescent mental health (pp. 29-59). Greenwich, CT: JAI Press.
9. Gould, M.S. (2001). Suicide and the media. In H. Hendin, & J.J. Mann (Eds.), The clinical science of suicide prevention (pp. 200-224). New York: Annals of the New York Academy of Sciences.
10. Fekete, S., & Macsai, E. (1990). Hungarian suicide models, past and present. In G. Ferrari (Ed.), Suicidal behavior and risk factors (pp. 149- 156). Bologna: Monduzzi Editore.
11. Robins, E. (1981). The final months: A study of the lives of 134 persons. NY: Oxford University Press.
12. Barraclough, B., & Hughes, J. (1987). Suicide: Clinical and epidemiological studies. London: Croom Helm.
13. Conwell Y., Duberstein P. R., Cox C., Herrmann J.H., Forbes N. T., & Caine E. D. (1996). Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. American Journal of Psychiatry, 153, 1001-1008.
14. Brent, D.A., Perper, J.A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: a case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32 (3), 521-529.
15. Shaffer, D., Gould, M.S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53 (4), 339-348
16. 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.
17. 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.
18. Fawcett, J. (1990).Targeting treatment in patients with mixed symptoms of anxiety and depression. Journal of Clinical Psychiatry, 51 (Suppl.), 40-43.
19. Gould, M.S., Fisher, P., Parides, M., Flory, M., & Shaffer, D. (1996). Psychosocial risk factors of child and adolescent completed suicide. Archives of General Psychiatry, 53, 1155-1162.
20. Moscicki, E.K. (1999). Epidemiology of suicide. In D.G. Jacobs (Ed.), The Harvard Medical School guide to suicide assessment and intervention (pp. 40-51). San Francisco: Jossey-Bass.
21. Ness, D.E., & Pfeffer, C.R. (1990). Sequelae of bereavement resulting from suicide.American Journal of Psychiatry, 147, 279-285.
22. Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: clinical aspects. British Journal of Psychiatry, 125,355-373.
23. Brent, D.A., Perper, J.A., Kolko, D.J., & Zelenak, J.P. (1988). The psychological autopsy: methodological considerations for the study of adolescent suicide.Journal of the American Academy of Child and Adolescent Psychiatry, 27 (3), 362-366.
24. Wasserman, I. M. (1984). Imitation and suicide: A re-examination of the Werther effect. American Sociological Review, 49, 427-436.
25. Rosenbaum, M. (1990). The role of depression in couples involved in murder-suicide and homicide. American Journal of Psychiatry, 47 (8), 1036-1039.
26. Nock, M.K., & Marzuk, P.M. (1999). Murder-suicide: Phenomenology and clinical implications. In D.G. Jacobs (Ed.) The Harvard Medical School guide to suicide assessment and intervention (pp. 188-209). San Francisco: Jossey-Bass.
27. Fishbain, D.A., D'Achille, L., Barsky, S., & Aldrich, T.E. (1984). A controlled study of suicide pacts. Journal of Clinical Psychiatry, 45,154-157.

Developed in collaboration with:
Centers for Disease Control and Prevention
National Institute of Mental Health
Substance Abuse and Mental Health Services
Administration Office of the Surgeon General
American Foundation for Suicide Prevention
American Association of Suicidology
Annenberg Public Policy Center

These recommendations were produced in the spirit of the public-private partnership recommended by the Surgeon General's National Strategy for Suicide Prevention.