Understanding Suicidal Depression

Suicidal depression isn’t a clinical diagnosis, but it’s a term you may see. Instead, most mental health professionals refer to it as “depression with suicidal thoughts.”

Clinical depression, or major depressive disorder (MDD), is a mood disorder. While there is not an exact cause for depression, Doreen Marshall, PhD, VP of Mission Engagement at the American Foundation for Suicide Prevention (ASFP), says it can be linked to a combination of factors such as physical brain structure, brain chemistry, hormones, or genetics.

When someone has clinical depression with suicidal ideation as a symptom, Marshall says it means that they are experiencing suicidal thoughts as part of their overall health symptoms. “However, it’s important to remember the vast majority of people who are depressed do not go on to die by suicide,” she explains.

Other symptoms of major depressive disorder or clinical depression include:

• lack of interest in usual activities
• changes in sleep and appetite (either increases or decreases)
• feelings of hopelessness
• feelings of sadness
• feelings of restlessness
• difficulty concentrating, thinking, or making decisions

“We should be mindful that thoughts of suicide can also occur outside the context of clinical depression and can occur with other mental health conditions, such as anxiety, post-traumatic stress, or substance use disorders,” she adds.

“It can be hard to know when someone may be thinking about suicide, so we encourage others to notice changes in behavior, thoughts, or mood that could indicate the presence of a worsening mental health condition,” she says.

However, she also says not to be afraid to ask someone if they have been having thoughts of suicide, especially if they are experiencing significant life stressors. Listen to the person without judgment and offer to stay with them until professional help arrives.

If you are concerned about what you are noticing or become aware that you or someone you know is having thoughts of suicide, Marshall says it’s important to reach out to a mental health professional for support and further help.

While not an exhaustive list, some of the more common signs that you or someone you know may be contemplating suicide include:

• making statements about feeling helpless, hopeless, and worthless
• large changes in mood
• talking about wanting to die
• expressing no reason to go on living
• withdrawing from friends, family, and social interactions
• writing about death
• giving away personal items
• participating in excessive alcohol or drug use
• aggressive behavior
• buying a weapon or collecting and saving pills
• saying goodbye to friends, family, and loved ones
• increase in anxious or agitated behavior

Some people separate suicidal ideation into passive and active categories. In this context, passive suicide refers to thoughts of suicide without a specific plan to carry it out. That said, Marshall points out that passive suicide is not a clinical term, and most mental health experts avoid it.

“Any thoughts of suicide are important to pay attention to, as they are often an indicator of distress,” says Marshall. “Occasionally, someone may express a non-specific wish to die, and it is important that we not be afraid to follow up and ask specifically if they are having thoughts of suicide and then take steps to connect them to help,” she adds.

Risk factors play a critical role in understanding suicide. That’s why Marshall says it is always important to have open and direct communication with someone if you think they are having thoughts of suicide and to take an extra step to notice and connect them to help.

“We are learning more every day about the factors that may contribute to suicidal ideation being part of clinical depression and know these can be biological and environmental in nature, as well as intersect with past history and life stressors,” says Marshall.

With that in mind, here are some of the common risk factors of suicide:

• family history of suicide
• substance misuse
• mood disorders, such as depression
• chronic illness
• previous suicide attempt
• significant losses or other sudden stressors
• history of trauma or family violence (physical or sexual abuse)
• your age, especial being ages 15 to 24 or over 60

There are many ways to treat clinical depression with suicide ideation, but Marshall says it can vary based on the severity and individual factors.

“As depression symptoms lessen through treatment, some people will see a decrease in frequency or intensity of suicidal ideation, but for others, this may not be the case, or their suicidal ideation may continue,” she says.

“Working with the individual to make sure they are safe during these times and can manage periods of suicidal ideation is a key component of safety planning in mental health treatment,” Marshall explains.

Marshall says there are also evidence-based treatments, such as dialectic behavioral therapy and cognitive behavioral therapy, that can help with both depressive symptoms and suicide.

“It’s important to let your mental health provider know that you are having thoughts of suicide, whether they accompany depressive symptoms or not, so your provider can plan the best treatment for you,” she says.

Medications such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and selective serotonin noradrenaline reuptake inhibitors (SNRIs) are the most commonly used antidepressants.

Along with the support of a mental health professional, Marshall says taking steps to stay healthy, connected, and proactive about your mental health needs can also help.

Here are some of her tips:

• practicing self-care such as getting regular sleep and exercise, and maintaining healthy nutritional practices
• having open, honest conversations about what you or someone else with depression with suicidal ideation may be experiencing and feeling
• learning and recognizing the warning signs of depression with suicidal ideation

Like other mental health conditions, early detection and treatment are critical factors to reducing suicide risk, according to the AFSP. “Adequate mental health treatment for clinical depression can help many people see a reduction in suicidal thoughts,” says Marshall.

But she also says it’s critical to seek support for suicidal thoughts that may be outside the context of clinical depression. “The important message is not to wait. And if you’re unsure whether you or someone you know is having thoughts of suicide — either as part of a depression diagnosis or separately — don’t be afraid to ask,” she explains.

The outlook for people with depression and suicidal ideation is positive, with the right treatment. A combination of psychotherapy, medication, and self-care can reduce depressive symptoms.

However, if thoughts of suicide worsen or increase in intensity, outpatient therapy may not be enough. In this case, in-patient treatment is often recommended.

Additionally, a new category — suicide behavior disorder (SBD) — has been recommended as a diagnosis for further study, according to a 2021 review article, and could possibly be accepted in a future iteration of the Diagnostic and Statistical Manual of Mental Disorders.

The goal of this proposal is to increase the chance that mental health experts will assess suicide risk beyond the suicidal ideation category in MDD.

Depression with suicidal ideation is not something you should manage on your own. If you’re currently in treatment for depression, make sure to tell your therapist you’re having suicidal thoughts.

If these thoughts or feelings are new to you, or if you’ve never reached out for help, ask a healthcare professional for a referral or contact a mental health expert in your area.

If you are having thoughts of harming yourself, you’re not alone. Help is available. Call a healthcare or mental health professional or a crisis line or prevention hotline to speak to someone who can help you find the support you need. Try the National Suicide Prevention Lifeline at 800-273-8255.

If you are in imminent danger of harming yourself or others, reach out to a trusted friend or family member, or call 911 or seek emergency medical care if you can’t reach someone you can trust.