For many surviving families and friends of suicide victims, the grief of loss is accompanied by shock and guilt.
They wonder if there were warning signs that they missed, or steps they might have taken to prevent the loss of a loved one. But even though there has been considerable study into suicide warning signs, they are far from clear.
A report on Oct. 22 by the British Medical Journal examined the experiences of 31 parents, partners, siblings and friends of 14 people between the ages of 18 and 34 who committed suicide. None of the victims was getting specialized mental health care.
The findings suggest the relatives and friends did not always get clear and unambiguous warning signals from the suicidal individuals, but even when it was obvious that something was seriously wrong, many of them feared confronting the person or seeking professional help for them.
"Even doctors with many years' training and experience find it very difficult to assess whether a person is at imminent risk of suicide," said Dr. Christabel Owens, the lead author of the study, who carried out the research at the Peninsula College of Medicine and Dentistry in Plymouth, England.
"Family members and friends find themselves in uncharted territory, with no training and little public information to guide them. They may know that a relative or friend is troubled, but have absolutely no idea that suicide is a possibility," she added.
Suicidal people may give direct hints, particularly when they've been drinking, that they're thinking of killing themselves, "but it is difficult for others to know how seriously to take these messages and how to respond to them," Owens said.
Public health experts estimate that 1 million people die by suicide worldwide each year, while in the United States, death certificates count about 36,000 taking their own lives annually.
Results of federal mental health surveys done in 2008-09 among adults 18 and older found that more than 8 million had serious thoughts of suicide and 2.2 million a year reported making suicide plans in the past year. About 1 million reported actually making a suicide attempt. All of those behaviors were more prevalent among those in the 18- to-29-year-old age range.
With approximately 4,600 suicides a year among Americans aged 10 to 24, suicide is the third-leading cause of death in this age group. And the National Institute of Mental Health estimates that among teens, there may be as many as 25 suicide attempts for each one that is completed, offering a significant opportunity for intervention to reduce the likelihood of future attempts.
A new study done by researchers at the University of California at Los Angles showed that a family-based intervention started when youths were still being treated in a hospital emergency department led to dramatic improvements in connecting the teens to follow-up care later.
Joan Asarnow, a professor of psychiatry, noted that a large proportion of youth seen in emergency departments for suicide don't get outpatient treatment after their discharge.
For the study, which involved 181 suicidal (either an attempt or expression of suicidal thoughts) youths at two Los Angles county emergency departments, participants were split into two groups. One got the usual level of care in the ER while the rest got an enhanced intervention that included a family-based crisis therapy session designed to motivate the teens and parents to seek further help.
Of those who got the enhanced intervention, 92 percent received follow-up treatment, compared with 76 percent in the standard care group. While those results are positive, Asarnow noted that follow-up checks done on the teens two months later didn't show much clinical or functional difference between the two groups.
Studies show that teenage boys are about four times more likely to complete a suicide attempt than girls, which makes it more difficult to spot and intervene with at-risk males.
Researchers note that more work needs to be done on how schools and communities react to teen suicides. Most experts say while it's not good to glorify the person or condone the act, neither should the death be ignored.
"Instead of focusing on the suicide itself, focus on what help is available and how people are responding to the grief. The focus should be on the community response," said Paul Granello, an assistant professor of counselor education at Ohio State University, who recently co-authored a book with his wife, also a professor at OSU, on dealing with suicides and violence in schools.
They, and others, stress that discussions about suicide should not be done in large assemblies, but rather in small group meetings that allow students to talk about their feelings and teachers or counselors to spot individual students who seem to be heavily impacted by the loss.
Here are some Web resources on suicide prevention and counseling: