Of primary and significant importance is that family and friends be watchful for signs of suicidal behavior. Suicidal behavior is not always obvious and is seldom predictable, but there are some signs that can trigger family and friends to ask more direct questions, such as, "Are you feeling suicidal at all?" It is okay to ask patients directly whether they are suicidal; there is not any danger that you will "put ideas in their head" as some family members and friends may fear.
Patients' risk for committing bipolar suicide may be elevated if they display any of the following behaviors:
- Talking about how they feel suicidal or want to die, or think the world would be a better place without them in it.
- Feeling hopeless, that nothing will ever change or get better
- Feeling helpless, that nothing one does makes any difference
- Feeling like a burden on family and friends.
- Abusing alcohol or drugs (this is a risk because drugs increase the likelihood that impulsive actions will take place)
- Putting affairs in order (e.g., organizing finances or giving away possessions to prepare for their death)
- Writing a suicide note
- Putting themselves into harm's way when this is not necessary, or into situations where there is a danger that they will be killed or seriously harmed.
While some bipolar suicide attempts are carefully planned over time, others are impulsive acts that have not been well thought out. It is very difficult to prevent the carefully thought out variety of suicides, but some basic precautions can help to minimize the risk for impulsive suicides. The simplest thing to do is to help patients to remove tools that they might use to harm themselves from their home. Guns should not be in the home, for instance (or if they must be in the home, they should be unloaded, and locked up. Unnecessary medications should not be available, and even necessary medications should not be available in quantities that could cause death. Similarly, razors, ropes, cables, saws, blades and other tools that might be used to slash or hang oneself should be removed from the home. There is not any practical way (short of complete imprisonment) to prevent someone from committing bipolar suicide if they are motivated to do so. A motivated patient can throw themselves in front of a car or train, or hang themselves with a shoelace. It is impractical to remove all such tools from patients' lives. However, taking some precautions to put obvious suicide tools out of immediate reach can and does reduce some suicidal risk.
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When patients indicate that they are feeling suicidal, or are experiencing suicidal thoughts, immediate action is appropriate:
- Call the patient's doctor or therapist, the local psychiatric (or medical) emergency room, or 911 right away so as to get immediate help and assistance.
- Make sure the suicidal person is not left alone
- Make sure that the suicidal person does not have access to large amounts of medication, to weapons, or to other items that could be used for self-harm (e.g., knives, etc.)
Because it is so difficult to accurately predict when people are actually at risk for committing suicide, it is generally appropriate to treat all instances of suicidality as real and serious threats, and to intervene every time. The risk of intervening every time, however, is that bipolar patients cease to talk about their suicidal thoughts after several false alarms, because they no longer want to be shuffled off to the hospital. Many patients will have ongoing low-level suicidal thoughts for long periods of time and not be in acute danger of acting on them. On the other hand, it is always possible for patients to impulsively act on long-standing suicidal thoughts if they happen to be triggered by particularly disturbing events or at an impulsive point in their mood cycle. The risk for bipolar suicide is highest when patients are in an impulsive state. Family members and friends have to use careful and conservative judgment when deciding whether to call in the professionals so as to balance patients' safety against damage to their relationships with patients if suicidal ideation should turn out to be a false alarm. When there is any doubt as to the seriousness of the suicidal threat, it is best to err on the side of safety and to call in the professionals.
Bipolar patients' suicidal crises are terribly frightening events for family and friends to endure. It is important that family and friends realize that such crises are a normal (if unfortunate) part of more severe bipolar illnesses, and that they will generally pass if the patient experiencing them can be helped through the crisis period.