Youth Suicide Ideation and How To Identify/Manage Suicidal Thoughts
Note: this article contains references and mentions of suicide/self-harm. If this is something you are sensitive or uneasy about, proceed with caution. Get additional support and information at https://www.sprc.org. Also, this is part two of a series by SJ Hart on suicide management. Read the first article here.
There is a misconception about suicidal ideation and how it expresses itself. I speak about this challenging topic at conferences and universities, and I also write in an attempt to shift the paradigm of this health crisis: an unremitting societal despondency, where people take their lives everyday with seemingly no signs or warnings. As a practicing clinician in the mental health field for twenty-two years, I thought my education and training provided me with the competency to treat complex clients with dual diagnoses. I was wrong.
I lacked the one experience needed to fully understand suicide. Suicidal ideation.
At the age of forty-three, with a family history of bipolar depression and my father’s suicide when I was twelve, nothing could prepare me for what lie ahead.
In March 2005, triggered by a migraine prevention medicine (a calcium channel blocker), I suffered my first catastrophic depressive suicidal episode. It was only then that I fully understood how inaccurate we’ve been, and why the number of attempts and completions continue to increase, despite prevention programs costing millions of dollars. It was only when I had my first of many episodes of suicidal ideation that I gained insight and knowledge of what is clearly a neurological symptom of chronic illness that is not preventable.
But it is most certainly manageable with the support of an informed and non-judgmental team.
Once I started discussing this openly, scores of people confided in me their experiences. They expressed feeling minimized and invalidated in a society where we only discuss motive, not looking any further into why people of all ages and walks of life take their lives in horrific and public ways.
Silence is often a combination of our self-stigma and judgement by others, as we believe we are alone in our personal hell. If family members and professionals start asking specific questions and discuss management with those we can confide in, we can find ways to actually help those of us who suffer from these terrifying moments. We might hear, “I don’t want to kill myself. I want the pictures and the pain to go away.” This is when real change begins.I asked people I knew in my community if I could share their stories for the purpose of suicide management education.
I went looking for young people to tell their story of ideation and management. I did not have to look far.
For many years, Kara worked as an advocate and discussed her own experience having suicidal ideations at age eighteen. Kara’s first psychiatric symptoms occurred when she was ten: including anxiety, periodic bingeing and purging, restricting and over exercising. Kara had two separate hospitalizations in the fall and spring of her senior year of high school. She attended college on a Lacrosse Scholarship and was the captain of the Lacrosse team. Kara graduated with an undergraduate’s degree in Psychology.
When discussing an oncoming episode, Kara says:
“The thoughts come immediately without warning. In my history of suicidal ideation, the pictures have been different episode to episode. The picture I’ve had more than once is swerving into traffic with my hands turning the steering wheel while driving in my car. Other random pictures have been rolling out of a moving vehicle, and going into the kitchen and getting a knife to cut or stab myself”.
I asked her about a management plan.
“When I am alone, if the picture is pulling my hands to swerve, I use a management technique where I break the moment down into small increments. Stop sign to stop sign, self-talk, put the windows up, shut the music off all to minimize distractions. I concentrate on safety, and hyper-focus on the destination to where I am driving. This usually occurs at night. After the episode I tell the details to people on my support team including my mother, my sister, and other family members. It has been six years since my last episode of suicidal ideation, and I still have a plan which I openly communicate with my husband who has not yet been a support to someone dealing with suicidal ideations. He has been more then wiling to learn.”
Kara is twenty-five, married, and working in the insurance industry. She is a Lacrosse coach, enjoys working out in moderation, and cooking.
Deaths from youth suicide are only part of the problem. More young people survive suicide attempts than die from them. A nationwide survey of high school students in the United States found that 16% of students reported seriously considering suicide, 13% created a plan, and 8% attempted it in the 12 months preceding the survey.
Each year, approximately 157,000 youth in the U.S. between the ages of 10 and 24 are treated in emergency departments for self-inflicted injuries. That’s the equivalent of 523 high schools with an enrollment of 3,000 nationwide. Or ten high schools per state. When the numbers are plugged into context, they are staggering.
Simon experienced suicidal ideation at age sixteen. Simon’s first severe psychiatric symptoms started at age three in Pre-K after several doses of prednisone for pneumonia. Ten days later, he started touching things compulsively, raging, and becoming destructive. At age four, he was diagnosed with OCD, anxiety, and bipolar spectrum disorder, and he has attended multiple outpatient treatments for thirteen years. His symptoms went into remission at age fourteen, but he’s had breakthrough symptoms on occasion, particularly around the full moon and seasonal change. He has an extensive family history of mental illnesses, with one relative completing suicide.
Once Simon stabilized, he was diagnosed on the autism spectrum as well, and last year he had his first severe episode of bipolar depressive suicidal ideation that lasted six months. Simon reports he is aware of an oncoming episode of suicidal ideation.
“I get pain in my chest, my thoughts are darker, I have a hard time thinking, my body slows down and I feel like I can’t move. I don’t say it out loud or tell anyone because then it becomes real. Once it becomes real, I fear getting overwhelmed with emotion, like I’ll break down and become unresponsive and not be able to function”.
Simon and his parents have worked with professionals and the school team pre-K to 12 over thirteen years.
“I read and use technology after I’ve told my parents and sometimes my IEP team in school (individualized education plan) needs to know. I was in school during a serious episode with really clear pictures of jumping out of the window, drinking lethal chemicals out of a beaker in chemistry class, and stabbing myself in the head with scissors. But after a crisis meeting, I went to school most days – occasionally half a day – and all my class assignments were modified. Everyone just had to know what was happening with my brain. I never fell behind.”
“Talking with friends and family and talking to a therapist is critical, but sometimes people don’t have those resources. My family members all have mental illnesses, and they all function, so I have a built-in team.If I didn’t have support, I wouldn’t tell anyone, and I would never call a hotline because they don’t understand ideation. People think suicide is always a behavior, but ideation comes in pictures, scary pictures. I distract the ideation by writing poems or stories, make a video game, or talk to my friends online who know about my anxiety.”
Simon is now seventeen and was recently accepted to a four-year university for Computer Science. He started a part-time job with the help of his vocational rehabilitation counselor, is a competitive chess player, writes poetry, and enjoys gaming, Dungeons and Dragons, and archery.
Though these are excruciating conversations to have, they are necessary to provide those who suffer with ideation a chance of survival from diseases that seek to end their pain permanently. My open discussions with courageous young people continued when I met Katelin through her mother. She knows about my work and felt that her story could help others open up. Katelin had some moderate symptoms of anxiety at age six and, when she was eighteen, the anxiety subsided. However, her first episode of suicidal ideation was four years earlier. Katelin’s depression was severe at that time when her twenty-five-year-old cousin hung himself and her grandparents were in failing health. She has suffered from suicidal ideation consistently on and off from age fourteen to now. She shared with me:
“I experience severe ideation every day.”
Note that I was unaware that Katelin was actively suicidal until we started talking. She was also on a new medication trial and experiencing images of suicidal methods in real time.
Katelin is aware of suicidal ideation including urges, pictures, and triggers since they come all the time.
“Jumping from buildings or building collapses, bridges, firearms, driving into a tree, sometimes hanging, taking bottles of medication, slitting my wrists, slitting my throat, and a plane crashing. There’s a lot more actually. My first major depressive episode was like a torturous slow-motion movie. I was more stable in high school; I played sports, did pretty well academically and had a social circle of friends.”
I caution anyone evaluating for suicidal ideation to use sensible judgment if discussing the pictures makes the person more distressed. It was only because I have known her mother for a long time who was in the room next door, and Katelin’s situation that I proceeded with care. Katelin had a clear look of anguish and torture common during a depressive episode with ideation.
Katelin went on:
“One thing I use a lot is a red stop sign, and I focus on the words and the line. My therapist recommended it. Or I try to think of something funny or comical happening. I tell my mom everything and let it all out and then talk with two of my friends. My friends will try to help me switch my focus to something else. When I’m able, I work out, hike, read, and hang out with family and friends. The pictures are still there, either quiet or loud. For right now, I am not doing well but I want to help others and let them know to keep fighting.”
Despite eleven years of chronic suicidal ideation, Katelin is currently working at a dog grooming & doggie daycare.
While finishing this article, I was referred to one of my friends’ colleagues. Claire had chronic suicidal ideation that started in college. She is thirty-eight and currently diagnosed with major depression and anxiety, with one manic episode. Claire is aware of the onset of the symptom of suicidal ideation, and it usually coincides with a major depressive episode.
“My mood changes, I feel irritable, and then about three weeks later, I say to myself: it’s coming. I feel like I’m barely getting through the day, like I’m in mud. My sleeping and eating are all over the place. I have no motivation, I don’t feel enjoyment, and, years ago, I didn’t shower regularly or get out of bed.”
“It started in my senior year of high school. My dad got very sick. At the time, I was told my depression was related to that. When he was better a while later, my family was relieved and happy, but I still felt really sad. I confided in a few people, and they brushed it off. They said I felt sad because of the situation with my father and that I hadn’t gotten over it yet. But looking back I’m pretty sure I had symptoms all through my childhood, starting in kindergarten, and this was probably my “trigger event.” I remember I was always anxious, and I thought everyone else felt that way too.”
Claire was very clearly differentiating between clinical depression and situational depression.
“During the first semester of my freshman year in college, I had my first episode of suicidal ideation, and I started seeing a psychiatrist. The images were terrifying when it happened. I had no idea where they came from or why I started seeing them. Again, I felt I was the only one to have these thoughts. I went to sign up for counseling because I knew I needed help, and when I met the first counselor, she said she was going on vacation and that I could make an appointment in two weeks. Thankfully, I immediately went to another counselor and started treatment. I had to leave school early that semester, as I wasn’t getting any better. I returned for the spring semester in January. Then one night, I impulsively took a large amount of pills – all different kinds. Soon after, I had five grand mal seizures, my heart stopped twice, and I was hospitalized for five days. I almost died.”
The next 10+ years of Claire’s life she described as catastrophic suffering with severe and debilitating depressive episodes that often included suicidal ideation. Claire is an example of the challenges college students have securing competent and accessible mental healthcare in school. She speaks clearly about the lack of education amongst professionals and that their training does not provide suicide management education.
Crisis on Campus reports that 6% of undergraduates and 4% of graduate students in 4-year universities have “seriously considered attempting suicide” in the past year – and nearly half of each group did not confide in anyone. On a campus of 15,000 with 10,000 undergraduate and 5,000 graduates, that’s 600 undergraduate students and 200 graduate students. A total of 800 attempts and 400 who don’t tell. That is one campus.
The suicide rate among young adults, aged 15-24, has tripled since the 1950s, and suicide is listed as the 2nd most common cause of death among college students. Twice as many young men, aged 20-24, commit suicide compared with young women. In the past fifty years, the suicide rate for those age 15-24 increased by over 200%.
Twelve people in that same young adult age group will commit suicide today.
That is one about every two hours.
Claire went on speaking:
“Last fall, I started feeling unstable, and I called my psychiatrist. He made some medication changes and after a few weeks of no improvement, a new antidepressant was added to my regimen. It flipped me into my first manic episode, and I stopped right away. I now do everything I can to be on top of my mental health. I tell my close friends when I am not well and my supervisor as well as my therapist. I started working with my current therapist six years ago, after the woman I was seeing wasn’t paying attention and looked bored every session we met. I’ve been empowered to take control of finding competent care. I know I don’t have to stay with someone and I would tell others the same.”
Claire completed her Bachelor’s degree in Elementary Education and a Masters in Special Education. She is a full-time teacher.
In 2017, there were an estimated 1,400,000 suicide attempts. That doesn’t account for the suicides that go unreported, and recently on American Idol, a show watched by many young people, two contestants discussed openly the attempted suicide and completed suicide of a sibling. Our young people are discussing suicide on television breaking through the stigma that has kept us silent for so long, while our country grieves several other completed suicides as they relate to chronic and deadly international social issues and PTSD. Though suicide is not preventable we must build management teams to confront this formidable opponent that never rests.
We may not have 100% success with suicide management teams, but it’s got to be better then what we’re doing now. Our goal is to reverse and reduce completed suicides. We cannot prevent ideation.
Suicidal ideations – whether they are images, visions, or something else – are symptoms! As I have personally experienced as well as hundreds I’ve interviewed, the symptoms appear as pictures in the mind. They are horrific and frightening films that increase the risk of attempting suicide, due to feelings of despair and hopelessness that accompany a dramatic mood shift.
When it lingers, we will do anything to make the pain go away! It's not that we want to die.
Does this account for all suicides? No.
Are there people who experience mood disorders differently? Yes.
Does treatment work? Sometimes.
In order to have an impact on reducing the completed suicide rate, we must shift the language and conversation to broaden the definition from suicide as a behavior to suicidal ideation as a symptom. We will validate millions of people who need to be heard, so they can speak openly and reach out of the dark for support and understanding. Until there is a shift, we will all watch in horror as our young people kill themselves and their families are forever traumatized. Suicide management offers a concrete plan for those who suffer with ideation, and a way for family and friends to take an active role.
The four young people who asked to tell their story for education have demonstrated how they suffered and endured while building a team to share the burden. They successfully developed suicide management teams to walk alongside them at the times they could not walk at all.
A human chain is stronger then one person standing alone. While we wait for medications that may or may not be accessible to those who suffer from suicidal ideation, suicide management has no cost, no co-pay, adds support quickly and can be accessed by most. We can all be part of a suicide management team once we learn the language of suicide ideation management. We must be willing to make the shift in order to reduce and reverse the rates of suicide and save one life at a time.