If you or someone you know is living with depression or bipolar disorder (also known as manic depression), you understand all too well that the symptoms may include feelings of sadness and hopelessness. These feelings can also include thoughts of self-harm or suicide. Whether we have suicidal thoughts ourselves, or know a severely depressed person who does, there are ways that we can respond with strength and courage.

Understanding Suicidal Thinking

The most important thing to remember about suicidal thoughts is that they are symptoms of a treatable illness associated with fluctuations in the body’s and brain’s chemistry. They are not character flaws or signs of personal weakness, nor are they conditions that will just "go away" on their own. Depression and the depressive phase of bipolar disorder may cause symptoms such as the following: 

Taken together, these symptoms may lead someone to consider suicide. However, with proper treatment the majority of people do feel better and regain hope. Recovery is possible.

During severe depression, the systems that regulate emotion become disturbed. People in the middle of a severe depression often think only of things that are dark and sad. Physicians refer to this as “selective memory”—only remembering the "bad times" or the disappointments in life. This type of thinking is a symptom of the illness; it does not define who the person is. And with proper treatment, the individual will start to remember the good times and develop a more positive outlook.

If You Are Feeling Suicidal

If you have begun to think of suicide, it’s important to recognize these thoughts for what they are: expressions of a treatable, medical illness. Don't let embarrassment stand in the way of vital communication with your physician, family or friends. Take immediate action and talk to somebody today. Remember, suicide is a permanent solution to a problem that is temporary.

When people don't understand the facts about suicide and depressive illnesses, they may respond in ways that can cut off communication and worsen their feelings. That's why it’s important to find someone you trust and can talk with honestly and openly. It's also why your mental health professional is an important resource in helping you—and your family.

What You Can Do to Fight Suicidal Thoughts

• Keep a journal to write down your thoughts. Each day, write about your hopes for the future and the people you value in your life. Read what you've written when you need to remind yourself why your own life is important.
• Go out with friends and family. When we are well, we enjoy spending time with friends and family. When we’re depressed, it becomes more difficult, but it is still very important. It may help you feel better to visit, or allow visits from, family and friends who are caring and can understand. 
• Avoid drugs and alcohol. Most deaths by suicide result from sudden, uncontrolled impulses. Since drugs and alcohol contribute to such impulses, it’s essential to avoid them. Drugs and alcohol also interfere with the effectiveness of medications prescribed for depression.
• Learn to recognize your earliest warning signs of a suicidal episode. There are often subtle warning signs your body will give you when an episode is developing. As you learn to manage your illness, you’ll learn how to be sensitive to them. They are signals to treat yourself with the utmost care, instead of becoming ashamed or angry with yourself.

Create a “Plan for Life”

Many depression-related suicides occur during someone’s first three depressive episodes—before he or she learns that an episode of suicidal thinking is temporary. As people learn from experience that any given episode will eventually pass, the likelihood that they’ll actually act on suicidal impulses drops sharply. It’s important to have a course of action ready before thoughts of suicide occur. Some people find it helpful to develop a “Plan for Life.” This plan lists warning signs you should watch for, and actions to take, if you feel that you’re slipping into suicidal thoughts. Your “Plan for Life” may include:

• Contact information for your doctor, including back-up phone numbers (emergency services, pager and mobile phone).
• Contact information for friends and family.
• A description of your medical diagnosis (or diagnoses, if more than one)—not just depression but any medical problems you may have. Also include information about any medications you are taking.
• Health insurance information.
• Contact information for a local suicide hotline.

Educate those you trust about your condition before it becomes a crisis, so that they can be prepared if they’re called on to help. Provide key support people with your “Plan for Life” so they can act quickly, if needed. Carry a copy of your Plan for Life with you at all times so you can refer to it or pass it along to someone else who might be helping you in a time of crisis. With all your important phone numbers in one place, it will be easier for someone to help.

Facts About Treatment

There are many different medications and therapies available for the successful treatment of depression. Not all medications work the same for all people, so it may take some time for you and your doctor to develop a treatment plan that’s right for you. Stick with it, and recognize that your doctor is your partner in this search.

Recognizing Warning Signs in Others

Sometimes, even health care professionals have difficulty determining how close a person may be to attempting suicide. As a friend or family member, you can't know for certain either. If you sense there is a problem, ask your friend or loved one direct questions and point out behavior patterns that concern you. Remind them that you care about them and are concerned. Talking about suicide with someone will not plant the idea in his or her head. If necessary, suggest that they make appointment to see their doctor and offer to go with them if you sense they would have difficulty doing it on their own. If you believe that immediate self-harm is possible, take them to a doctor or hospital emergency room immediately.

Warning signs may include the following:

• Feelings of despair and hopelessness
  Often times, individuals with depression talk with those closest to them about extreme feelings of hopelessness, despair and self-doubt. The more extreme these feelings become, and the more often they’re described as "unbearable," the more likely it is that the idea of suicide may enter the person's mind.
• Taking care of personal affairs
  When a person is "winding up his or her affairs" and making preparations for the family's welfare after he or she is gone, there is a good chance the individual is considering self-harm or suicide.
• Rehearsing suicide
  Rehearsing suicide, or seriously discussing specific suicide methods, are also indications of a commitment to follow through. Even if the person's suicidal intention seems to come and go, such preparation makes it that much easier for the individual to give way to a momentary impulse.
• Drug or alcohol abuse
  Someone with worsening depression may abuse drugs or alcohol. These substances can worsen symptoms of depression or mania, decrease the effectiveness of medication, enhance impulsive behavior and severely cloud judgment.
• Beginning to feel better
  It might sound strange, but someone dealing with depression may be most likely to attempt suicide just when he or she seems to have passed an episode's low point and be on the way to recovery.
  
  Experts believe there’s an association between early recovery and increased likelihood of suicide. As depression begins to lift, a person's energy and planning capabilities may return before the suicidal thoughts disappear, increasing the chances of an attempt. Studies show that the period six to 12 months after hospitalization is when patients are most likely to consider, or reconsider, suicide.

Responding to an Emergency Situation

If someone is threatening to commit suicide, if someone has let you know they are close to acting on a suicidal impulse or if you strongly believe someone is close to a suicidal act, these steps can help you manage the crisis:

• Take the person seriously. Stay calm, but don't underact.
• Involve other people. Don't try to handle the crisis alone or jeopardize your own health or safety. Call 911 if necessary. Contact the individual's doctor, the police, a crisis intervention team or others who are trained to help.
• Express concern. Give concrete examples of what leads you to believe the person is close to suicide.
• Listen attentively. Maintain eye contact. Use body language such as moving close to the person or holding his or her hand, if appropriate.
• Ask direct questions. Find out if the person has a specific plan for suicide. Determine, if you can, what method of suicide he or she is considering.
• Acknowledge the person's feelings. Be understanding — not judgmental or argumentative. Do not relieve the person of responsibility for his or her actions.
• Offer reassurance. Stress that suicide is a permanent solution to a temporary problem. Remind the person that there is help and things will get better.
• Don't promise confidentiality. You may need to speak to the person's doctor in order to protect the person from himself or herself.
• Make sure guns, old medications and other potentially harmful items are not available.
• If possible, don't leave the person alone until you're sure he or she is in the hands of competent professionals. If you have to leave, make sure another friend or family member can stay with the person until professional help is available.

What You Can Do to Help Someone

Among the many things you can do to help someone who is depressed and may be considering suicide, simply talking and listening are the most important. Do not take on the role of therapist. Often, people just need someone to listen. Although this might be difficult, the following are some approaches that have worked for others:

• Express empathy and concern.
  Severe depression is usually accompanied by a self-absorbed, uncommunicative, withdrawn state of mind. When you try to help, you may be met by your loved one’s reluctance to discuss what he or she is feeling. At such times, it’s important to acknowledge the reality of the pain and hopelessness he or she is experiencing. Resist the urge to function as a therapist. This can ultimately create more feelings of rejection for the person, who doesn't want to be "told what to do." Remain a supportive friend and encourage continued treatment.
• Talk about suicide.
  Talking about suicide does not plant the idea in someone’s head. Your ability to explore the feelings, thoughts and reactions associated with depression can provide valuable perspective and reassurance to your friend or loved one who may be depressed. Not everyone who thinks of suicide attempts it. For many, it's a passing thought that lessens over time. For a significant number of people, however, the hopelessness and exaggerated anxiety brought on by untreated or under-treated depression may create suicidal thoughts that they can’t easily manage on their own. For this reason, take any mention of suicide seriously.
  
  If someone you know is very close to suicide, direct questions about how, when and where he or she intends to commit suicide can provide valuable information that might help prevent the attempt. Don’t promise confidentiality in these circumstances. It’s important for you to share this information with the individual’s doctor.
• Describe specific behaviors and events that trouble you.
  If you can explain to your loved one the particular ways his or her behavior has changed, this might help to get communication started. Compounding the lack of interest in communication may be guilt or shame for having suicidal thoughts. Try to help him or her overcome feelings of guilt. If there has already been a suicide attempt, guilt over both the attempt and its failure can make the problem worse. It’s important to reassure the individual that there’s nothing shameful about what they are thinking and feeling. Keep stressing that thoughts of hopelessness, guilt and even suicide are all symptoms of a treatable, medical condition. Reinforce the good work they’ve done in keeping with their treatment plan.
• Work with professionals.
  Never promise confidentiality if you believe someone is very close to suicide. Keep the person’s doctor or therapist informed of any thoughts of suicide. If possible,  encourage them to discuss it with their doctor(s) themselves, but be ready to confirm that those discussions have taken place. This may involve making an appointment to visit the doctor together or calling the doctor on your own. Be aware that a doctor will not be able to discuss the person’s condition with you. You should only call to inform the doctor of your concern.
  
  Whenever possible, you should get permission from your loved one to call his or her doctor if you feel there’s a problem. Otherwise, it could be seen as "butting in" and may worsen the symptoms or cause added stress. Of course, if you believe there is a serious risk of immediate self-harm, call his or her doctor. You can work out any feelings of anger the person has towards you later.
• Stress that the person's life is important to you and to others.
  Many people find it awkward to put into words how another person's life is important for their own well-being. Emphasize in specific terms to your friend or loved one how his or her suicide would devastate you and others. Share personal stories or pictures to help remind your loved one of the important events in life you’ve shared together.
• Be prepared for anger.
  The individual may express anger and feel betrayed by your attempt to prevent their suicide or help them get treatment. Be strong. Realize that these reactions are caused by the illness and should pass once the person receives proper treatment.
• Always be supportive.
  People who have thought about, or attempted, suicide will most likely have feelings of guilt and shame. Be supportive and assure them that their actions were caused by an illness that can be treated. Offer your continued support to help them recover.
• Take care of yourself.
  It’s not uncommon for friends and family members to experience stress or symptoms of depression when trying to help someone who is suicidal. You can only help by encouraging and supporting people through their own treatment. You cannot get better for them. Don’t focus all of your energy on the one person. Ask friends and family to join you in providing support and keep to your normal routine as much as possible. Pay attention to your own feelings and seek help if you need it.