AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

INTRODUCTION AND DEFINITIONS

Section 2 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

Suicide ranks as the eighth leading cause of death in the United States. In certain populations, such as adolescents and young adults, it constitutes 1 of the top 3 causes of death. This phenomenon is even more compelling because, in many instances, suicides can be prevented. Therefore, clinicians must recognize the risk factors as a way of intervening in a self-destructive event and cycle. This article examines suicide and is divided into 4 sections.

• The first deals with the basic definitions as applied to self-destructive activities and events.
• The second presents risk factors that can alert the clinician to early warning signs of suicide.
• The third looks at interventions if a person's attempt at suicide is imminent.
• Finally, the fourth section reviews appropriate actions for a clinician if a person he or she is treating does commit suicide.

Definitions

Suicide means killing oneself. The act constitutes a person willingly, perhaps ambivalently, taking his or her own life. Several forms of suicidal behavior fall within the self-destructive spectrum.

• A suicide attempt involves a serious act, such as taking a fatal amount of medication, and someone intervening accidentally. Without the accidental discovery, the individual would be dead.
• A suicide gesture denotes a person undertaking an unusual, but not fatal, behavior as a cry for help or to get attention.
• A suicide gamble is, for example, to ingest a fatal amount of drugs with the belief that family members will be home before death occurs. Patients gamble their lives that they will be found in time and that the discoverer will save them.

RISK FACTORS AND PREVENTION

Section 3 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

A number of factors correlate with serious suicide attempts and completed suicides. They constitute risk factors, which will be reviewed in the following categories: (1) demographics, (2) characteristics and behaviors, (3) life experiences, (4) mental illnesses, and (5) psychodynamic formulation.

Demographics

Although these demographics are discussed individually, several demographic factors often occur in the same person. For example, a police officer with major depression and a significant problem with alcohol commits suicide using his service revolver. (Unfortunately, this happens not infrequently.) This self-destructive event involves 5 risk factors—sex, occupation, depression, alcohol, and gun availability.

• Sex
  • The sex of the person who attempts or commits suicide represents one of the most salient and enduring features in self-destructive statistics. Men commit suicide far more frequently than women. In the United States, the difference is quite striking. In 1995, the suicide rate for men was 18.6 occurrences per 100,000 population, and for women it was 4.1 occurrences per 100,000 population. However, women make far more attempts than men.
  • Although the facts allow many interpretations, such as method (men use guns and women use pills) and ability to handle feelings, the fact remains that difference in frequency related to sex is a powerful and relatively consistent finding across a wide range of other demographic categories, such as age, socioeconomic factors, and region.
• Age
  • In general, the suicide rate increases with age, with a major significant spike in adolescents and young adults.
  • In recent decades, a dramatically higher number of adolescent suicides has occurred.
  • With increasing age, a critical relationship emerges between suicide and being old. Geriatric suicide is extremely prevalent. People older than 65 years have the highest rate of suicide. That age group also maintains an alarming connection with murder-suicides.
  • A number of other factors are closely linked to suicide. These include losses, such as a job, a loved one, a pet, and divorce. People who are married are less suicidal than those who are single, divorced, or widowed. Isolated individuals are at greater risk than those involved with others and their community.
• Ethnicity
  • In the United States, the majority of suicides occur within the white population.
  • In men, the rate for white men in 1995 was 19.7 cases per 100,000 population, for black men it was 12.4 cases per 100,000 population, and for Hispanic men it was 12.3 cases per 100,000 population. However, the rate for Native American men was 20.1 cases per 100,000 population for the same year.
  • Furthermore, in sampling surveys (one from 53 countries and one from 43 countries), Voracek et al found that regardless of sex or age, people with a lighter skin color have a higher rate of suicide than those with darker skin color (Voracek, 2006).
• Religion
  • Historically in the United States, Protestants have a higher rate of suicide than either Catholics or Jews.
  • Some religions may encourage suicide in situations of disgrace or for patriotic reasons.
• Geography
  • In the United States, certain states have higher suicide rates than others. For example, in 1999, the suicide rate by state ranged from 6.6 cases per 100,000 population to 24.8 cases per 100,000 population in Nevada.
  • Examining the nation regionally, the Western states have the highest suicide rates, with the exception of Vermont.
  • Living in rural areas carries a higher risk of suicide than living in urban areas (Macionis, 2003).
  • Globally, a remarkable range in rates exists. The highest rates for men are in Hungary and Finland. The United States is in the middle, and the lowest rates are in Greece, followed by Mexico and the Netherlands.
• Season
  • Most suicides occur in the spring. The month of May has been noted for its high rate of suicide.
  • The speculation is that during the winter and early spring when people are depressed, they often are surrounded by others who are feeling downhearted because of the weather. However, with the arrival of the spring season and the month of May, people who are depressed because of the weather are cheered and people who are depressed for other reasons remain depressed. As others cheer up, those who remain miserable must confront their own unhappiness.
  • Lack of daylight correlates with depression and suicide.
  • The regions with long, dark winters have high suicide rates, such as Scandinavia and parts of Alaska, such as Nome. Certainly, persons with seasonal affective disorders (SAD) who live in these regions experience depression in the absence of sunlight and, hence, have a higher susceptibility to depression.
• Professions and occupations
  • Police or public safety officers are at risk for suicide. The hours of work, the scenes they witness daily, the availability of guns, and the silence encouraged by the profession (keeping within the "wall-of-blue"), as well as alcohol usage and divorces contribute to this risk.
  • Physicians, especially those who deal with progressively terminally ill patients, have a high rate of suicide. In the United States, the medical field loses the equivalent of a medical school class each year by suicide.
  • Dentists have a high suicide rate. Perhaps, elements of obsessive and perfectionist tendencies combined with personal feelings of isolation may contribute to this high number of self-induced deaths.
• Social-cultural-economic factors
  • In certain cultures, suicide is considered more acceptable than in others. For example, the Japanese culture often regarded suicide as an honorable solution to certain situations.
  • Times of economic change, especially economic depressions, have been associated with suicides. The start of the Great Depression in the United States was accompanied by a number of suicides.
  • Emile Durkheim noted that in times of major societal alternations, when the rules are in flux and people do not know what is expected of them, the self-destructive rate increases. He termed this period of cultural changes anomie.
  • Poverty and low income, with concomitantly fewer options and opportunities, correlate with suicide (Agerbo, 2006).

Internet and other media and suicide

The Internet can be a suicidal factor in negative and positive ways. The internet, as other literature, can provide information concerning "how to" methods. One patient, after reading the book Final Exit, used one of the methods described to complete a suicide. Furthermore, antipsychiatric Internet sites are available that decry mental health explanations and show ways to be more effective at being anorexic. On the other hand, a number of sites provide encouragement for treatments, accounts of successful interventions, and key resources (Alao, 2006).

Availability of firearms

The leading method of suicide remains firearms (Shield, 2006). A person with a depressed mood, along with alcohol consumption and the availability of a handgun, can turn the scene from a "pity party" into a lethal event. Therefore, a psychiatrist must not only inquire into the patient's suicidal ideation and plans but also the presence of firearms. Clinicians also must know their state statues concerning persons with mental illness possessing firearms (Norris, 2006).

Medical conditions

Patients with protracted, painful, progressive medical conditions are at risk for suicide. For example, patients undergoing dialysis for end-stage renal disease have a higher rate of suicide than that of the general population (Kurella, 2005). Other diseases conferring higher risk include chronic obstructive pulmonary disease, cancer, HIV infection/AIDS, quadriplegia, multiple sclerosis, severe whole-body burns, and chronic heart failure. The combination of cancer and age is particularly lethal (Labisi, 2006). Persons experiencing increasing intractable pain are at particularly high risk for suicide.

Suicidal thoughts, behavior, and characteristics of people who are self-destructive

A host of thoughts and behaviors are associated with self-destructive acts. Although many assume that people who talk about suicide do not follow through with it, the opposite is true. Those who threaten suicide actually do kill themselves. Suicidal ideation is highly correlated with suicidal behaviors. Furthermore, in addition to thinking and talking about suicide, the patient is actually planning it. The potential for a self-destructive act definitely increases.

• A number of activities are associated with committing suicide.
  • Making a will
  • Getting the house and affairs together
  • Unexpectedly visiting friends and family members
  • Purchasing a gun, hose, or rope
  • Writing a suicide note
  • Visiting a primary care physician: A significant number of people see their primary care physician within 3 weeks before they commit suicide. They come for a variety of medical problems. Rarely will they state they are contemplating suicide; yet, they do visit their doctors. Therefore, the practitioner must pay attention to the entire person—the physician must look for other things in the patient's life in addition to the chief complaint.
• Individuals who are suicidal have a number of characteristics.
  • A preoccupation with death
  • A sense of isolation and withdrawal
  • Few friends or family
  • An emotional distance from others
  • Distraction and lack of humor: They often seem to be "in their own world" and lack a sense of humor (anhedonia).
  • Focus on the past: They dwell in past losses and defeats and anticipate no future. They voice the notion that others and the world would be better off without them.
  • They are haunted and dominated by hopelessness and helplessness. They are without hope and therefore cannot foresee things ever improving. This is a terrible feeling. They also view themselves as helpless in 2 ways. First, they cannot help themselves. All their efforts to liberate themselves from the sea of depression in which they are drowning are to no avail. Second, no one else can help them.

Recent life experiences

Certain recent life events can precipitate suicidal behavior. These include losses in the romantic area, such as the termination of a love relationship or a divorce, or a job termination. The acute loss can be very devastating, as evidenced by the case of an ED nurse who was fired for her drug use and immediately went home and committed suicide (Yen, 2005).

Past life experiences

A number of life events are linked to the act of committing suicide. The most important is suicide by a family member or a friend. Not infrequently, history of a father, mother, or sibling committing suicide correlates with suicide by another member of that family. For example, when a boy was 5 years old, he witnessed his mother kill herself by shooting herself in the head. Later, after several attempts, he killed himself.

Suicides by friends provoke others to duplicate the event. Especially in adolescents, suicide has a contagious aspect. Not uncommonly, one suicide in a high school is followed by other suicides or attempts.

A history of physical, emotional, or sexual abuse is linked to suicide. Persons with posttraumatic stress disorders (PTSDs) are particularly vulnerable. Damage to the person leads to self-destructive actions.

Other deaths, especially by family members, are linked to suicide. For example, a young child killed himself because he wanted to "join mommy in heaven." Family members had told him that after his mother died she was in heaven with God. In his view, his suicide allowed him to be with her again.

Mental illness

Although mental illness is generally linked to premature deaths, certain mental illnesses carry with them a remarkably high lifetime instances of suicide. In fact, 95% of people who commit suicide have a mental illness. Hospitalization for a psychiatric disorder is quite prevalent in the suicidal population (Agerbo, 2006). This includes people with any depressive disorder, manic-depressive illness (bipolar illness), schizophrenia, PTSD, phobias, substance abuse, delirium, and dementia, as well as certain genetic factors. In a general sense, mental illness all too often is an isolating experience, and that isolation correlates with suicide.

• Depression
  • Because depression involves a preoccupation with death, the twin killers of hopelessness and helplessness, and withdrawal, it is a major contributor to suicide (see Depression).
  • A dangerous time in depression occurs when a patient is coming out of the deepest part of the experience. At that point, they can mobilize their newly acquired energy to take their own life.
  • The protracted and profound emotional roller coaster of manic-depressive illness puts the person at risk both during the depressive phase and in the psychosis of mania (see Bipolar Affective Disorder).
  • One important consideration in the treatment of depression is that SSRIs have a lower rate of fatal overdoses than tricyclics (Barak, 2006).
• Schizophrenia
  • These patients are at a significantly high risk for suicide (see Schizophrenia).
  • They may experience hallucinations, often auditory, such as voices commanding them to kill themselves (command hallucinations).
  • They may, in the context and as a result of their illness, become depressed. They realize that they are different from others.
  • They may also have moments of insight during which they realize that they may achieve some life goals that others can accomplish.
  • Persons with schizophrenia who are considered highly functional seem to be at high risk for suicide. This is perhaps because of their ability to appreciate how they are and how they are different, both from others and from what they wish their lives might be.
  • Finally, the suspicions and fears associated with schizophrenia may promote isolation and withdrawal.
• Anxiety disorders
  • Obsessive-compulsive disorder (OCD) and phobic disorders have symptoms that make suicide a possibility.
  • Persons struggling with these symptoms feel frightened, terrorized, isolated, and physically paralyzed by feelings of anxiety, panic, and dread that often seem inexplicable. In many instances, people feel the symptoms are growing, expanding, and incapacitating.
  • For example, a woman with agoraphobia became progressively more isolated and depressed by her inability to leave her home (see Anxiety Disorders, Obsessive-Compulsive Disorder, and Social Phobia).
• Posttraumatic stress disorder
  • Survivors of trauma, whether it is childhood sexual abuse or a recent physical devastation, struggle with flashbacks and nightmares.
  • They frequently alternate between periods of hyper-vigilance and periods of psychic numbing.
  • They have feelings of being damaged and feelings of guilt. As a result, they have a high rate of suicide (see Posttraumatic Stress Disorder).
• Substance abuse
  • Substances contribute to self-destructive behaviors in all 3 phases of their use—intoxication, withdrawal, and chronic usage.
  • A depressed person commonly becomes acutely suicidal after a few drinks.
  • Similarly, some people can become suicidal after ingesting lysergic acid diethylamide (LSD).
  • Others encounter a depression during substance withdrawal and respond with killing themselves.
  • A person with chronic alcohol and drug use often experiences a number of major losses, such as a job, spouse, and family, and these in turn contribute to becoming suicidal (see Alcoholism; Opioid Abuse; Toxicity, Cocaine; and Hallucinogens).
  • Even those in drug recovery programs remain at risk. For example, persons in opiate dependency programs, especially those with chronic pain, those with the availability of firearms, those using other street drugs, and those new to the program are at particular risk (Thompson, 2006).
• Delirium and dementia
  • Delirium and dementia involve loss of memory, disorientation, hallucinations, delusions, and poor judgment (see Delirium and information on dementia).
  • These conditions often lead to self-destructive behavior.
  • For example, an accountant slowly starts to have difficulty remembering numbers and performing addition problems. Although others view these problems as minimal, he feels he is losing his mind and career. He takes his life.
• Other mental illnesses
  • As noted, mental disorders carry with them elements of despair and withdrawal. This list represents other mental disorders where self-destructive behavior is prevalent.
  • Bulimia has been accompanied by suicidal activity. Predisposing factors include feelings of loneliness, stimulant use, family history of psychiatric disorders, childhood abuse, and difficulty dealing with the public (Nickel, 2006).
• Genetics
  • Some authorities believe that genetic factors alone may be involved, that suicide runs in families, and that having a relative who commits suicide is indeed a risk factor. Therefore, a family history of suicide is very significant. Careful assessments of family history of mental illness and suicide should be a routine aspect of patient evaluation.
  • Studies continue to show the gene connection in suicidal behavior. Genes related to serotonin have be implicated in histories of second suicide attempt (Courtet, 2004).
  • Certainly, many of the above listed mental illnesses (eg, manic-depressive illness) are not only risk factors, but also have strong genetic components.

Psychodynamic formulation

Several individual psychodynamic ways of viewing suicide exist. In one situation, patients deflect anger inward to hurt themselves when they want to strike out at others. For example, a young man grounded by his parents for misbehavior takes an overdose to punish them.

Alternately, the psychoanalytic notion of incorporation and killing the interject exists. In this situation, patients have unconsciously incorporated an ambivalently held object (eg, a family member). For example, a man incorporates his father. He then attacks the interject (father) by killing himself.

INTERVENTION

Section 4 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

In many cases, swift, decisive intervention can prevent a person from committing suicide. Because of this preventable aspect to suicide, recognizing and taking action if the potential arises is critical. Intervention is based upon the application of risk factors coupled with a clinical inquiry.

• Assessment
  • A clear and complete evaluation and clinical interview provide the information upon which to base the intervention. Although risk factors offer major indications of the suicide danger, nothing can substitute for a focused patient inquiry.
  • A number of questions must be asked during the assessment.
    • Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this question. They fear the inquiry may be too intrusive or that they may provide the person with an idea of suicide. In reality, patients appreciate the question as evidence of the clinician's concern. A positive response requires further inquiry.
    • If suicidal ideation is present, the next question must be about any plans for suicidal acts. The general formula is that more specific plans indicate greater danger. Vague threats, such as suicide occurring sometime in the future, are reason for concern. However, responses indicating that the person has purchased a gun, has ammunition, has made out a will, and plans to use the gun are more dangerous. The plan demands further questions. If the person envisions a gun-related death, determine whether he or she has the weapon or access to it.
    • Determine what the patient believes his or her suicide would achieve. This suggests how seriously the person has been considering suicide and the reason for death. For example, some believe that their suicide would provide a way that family or friends would realize their emotional distress. Others see their death as relief from their own psychic pain. Still others believe that their death would provide a heavenly reunion with a departed loved one. In any scenario, the clinician has another gauge of the seriousness of the planning.
    • Any question of suicide also must be coupled with an inquiry into the person's potential for homicide. Suicide often is thought to represent aggression turned inward, while homicide represents aggression turned outward. Because suicide constitutes an aggressive act, the question regarding homicidal tendencies must be asked.
    • Collateral questions should be asked based the reviewed risk factors. These questions deal with any family members or friends who have killed themselves. They include questions about symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse.
  • The clinician's gut feeling
    • Although all the answers may be inclusive, often, a therapist develops a visceral sense that his or her patient is actually going to commit suicide.
    • The clinician's reaction counts and should be considered in the intervention.
  • Other sources
    • In addition to the material obtained through the clinical interview, information from other sources includes family interviews or interviews with friends or coworkers.
    • First responders or other medical personnel may have key information.
    • A suicide note may have been written.
    • A number of tests (paper and pencil) will indicate both the presence of a significant depression and significant thoughts and plans of self-destruction. These include the following self-administered tests: Beck Depression Inventory, Hamilton Depression Rating Scale, the HANDS (Harvard Department of Psychiatry/National Depression Screening Day Scale) Depression Screening Questionnaire, and the Minnesota Multiphasic Personality Inventory.
    • Utilize all information available.
• Intervention
  • Based on all the information, if the person is indeed suicidal, a number of steps should be taken.
    • First, the individual must not be left alone. In the emergency department, such a recommendation is handled easily by hospital security personnel. In other settings, summon assistance quickly. In an isolated place, call 911. Involve family or friends. They can remain with the patient while treatment arrangements are made.
    • Remove anything that the patient may use to hurt or kill him or herself. Remove sharp or potentially dangerous objects. Ask the patient for any weapon, such as knives or pills. Secure them.
    • The suicidal patient is treated initially in a secure, safe, and highly supervised place. Inpatient care at a hospital offers one of the best settings. Most managed care companies recognize the medical necessity of hospitalization in situations in which the suicide danger is acute.
  • Suicide constitutes an immediate solution to an underlying problem. The critical factor is first to keep the patient alive and treat the underlying condition. Once the person is safe, start a series of outpatient treatments in less restrictive settings.

POSTVENTION

Section 5 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

Despite the best care and intervention, people still kill themselves. This section details steps a clinician should take if a patient succeeds in committing suicide. Practitioners must work with the patient's family and friends, with the other patients who knew the decreased, and with him or herself (Kaye, 1991).

Upon learning of the death of a patient, focus on the immediate situation. Reschedule other patients. Whenever possible, meet with the family. They appreciate the clinician's interest and the opportunity to voice their feelings and reactions. In some situations, the family may have expected the outcome. In others, they are hurt and angry. The clinician's job is to be responsible and responsive to them. This intervention may require more than one session. Be available to them, listen, and share their loss.

Often, other patients knew the deceased patient. Without violating confidentiality, provide extra attention to these patients. This could include sessions to allow them to express their reactions to the death and the loss. If the patient who committed suicide was an inpatient, convening a group meeting and discussing the other patients' reactions is important. The staff also should have an opportunity to discuss their feelings.

Finally, the practitioner must take time to review and discuss the event. Often, seeking a senior clinician is effective. The therapist needs an opportunity to recover and heal. Later, a psychological autopsy can be performed, but, in the acute phase, the clinician requires sympathy and support.

CONCLUSION

Section 6 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

• Suicide is the eighth leading cause of death in the United States.
• In many cases, suicide can be prevented.
• Recognition of risk factors as indicators is critical.
• Depression, isolation, prior suicide attempts, substance abuse, and serious mental illness rank as highly significant contributors.
• Swift and decisive interventions based upon a thorough assessment can save lives.
• If the patient does commit suicide, a number of steps can and should be undertaken for the patient's family, other patients, the staff, and the therapist.

For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education articles Depression and Suicidal Thoughts.

THE 12 THINGS THAT ALERT TO A REAL SUICIDE POTENTIAL

Section 7 of 8  

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

1. Patients with definite plans to kill themselves: People who think or talk about suicide are at risk. However, a patient who has a plan, eg, to get a gun and buy bullets, has made a clear statement regarding risk of suicide.
2. Patients who have pursued a systematic pattern of behavior in which they engage in activities that indicate they are leaving life: This includes saying goodbye to friends, making a will, writing a suicide note, and developing a funeral plan.
3. Patients with a strong family history of suicide: Family history of suicide is especially indicative of suicide risk if the patient is approaching the anniversary of such a death or the age at which the relative committed suicide.
4. The presence of a gun, especially a handgun
5. Being under the influence of alcohol or other mind-altering drugs: Drug abuse is especially significant if the drugs are depressants.
6. If the patient encounters a severe, immediate, unexpected loss: This happens when a person is fired suddenly or left by a spouse.
7. If the patient is isolated and alone
8. If the person has a depression of any type: The twin aspects of depression—hopelessness and helplessness—take a significant toll. The person sees no hope or any possibility of hope. The person views the world as black and anticipates no end to the blackness. Furthermore, the patient's self-perception is that he or she is beyond help; nothing has helped and nothing will help. This type of depression can occur in the context of medical or mental disorders. Persons with progressive, fatal, painful illnesses, such as chronic obstructive pulmonary disease (COPD) or cancer, are at high risk for suicide. Persons with mental disorders, such as schizophrenia, perceive the realty of their disease and the losses it has brought. In the midst of an anxiety disorder or Alzheimer disease, the person feels despair and depression.
9. If the patient experiences command hallucination: A command hallucination ordering suicide can be a powerful message of action leading to death.
10. Discharge from psychiatric hospitals: Patients upon discharge from psychiatric hospitals are at risk. Hospital discharge is a very difficult time of transition and stress. The structure, support, and safety of the institution are no longer available to the patient. The patient feels apprehension and is confronted with the reality of change. This all translates into fright and vulnerability.
11. Anxiety: Anxiety in all of its forms causes the risk for suicide. The constant sense of dread and tension proves unbearable for some.
12. Clinician's feelings: Finally, regardless of what the patient says or does, if the clinician has a feeling that patient is going to commit suicide—consider it a sixth sense or great clinical intuition—the clinician's feelings matter. They are part of clinical judgment and are an important part of the suicide assessment and intervention.

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction and Definitions
• Risk Factors and Prevention
• Intervention
• Postvention
• Conclusion
• The 12 Things That Alert to a Real Suicide Potential
• References

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Article Last Updated: Sep 28, 2006