Field notes · Mind & brain · Keeping people safe

Keeping people safe. What actually prevents suicide, and what each of us can do.

I have spent a good part of my career around this subject — first as a young researcher at the University of Utah collecting stories and DNA from families who had lost someone, later as a psychiatrist trying to keep the people in front of me alive. Here is what I've learned, what the evidence says, and how to check in on someone you love.

If you are in crisis right now

Call or text 988 (US, 24/7, free). Text HOME to 741741 to reach a crisis counselor by text. Veterans: call 988 and press 1. In Utah, the SafeUT app connects you to licensed counselors any hour. Outside the US: findahelpline.com.

If you are with someone who is in danger right now, stay with them and call 988 or go to the nearest emergency room together. You don't have to know what to say. You just have to stay.

48,800Americans died by suicide in 2024 — 13.7 per 100,0001
≈ 10 minHalf of survivors say the decision-to-action interval was ten minutes or less2
9 in 10People who survive an attempt and never go on to die by suicide3,4
135People affected by each death5

First, the thing I most want you to know

Suicidal crises are usually temporary, ambivalent, and survivable. That sentence carries most of the science, so let me unpack it.

Temporary. When researchers interview people who survived a serious attempt, roughly half say the interval between deciding and acting was ten minutes or less2, and in a separate US study a quarter said under five minutes6. The acute, unbearable state — what the suicidologist Edwin Shneidman called psychache7 — tends to crest and pass. This is why "getting through the next hour" is not a platitude; it is the mechanism.

MINUTES HOURS → DAYS the window that matters INTENSITY Anything that slows the moment down — a person, a call, a locked drawer — works here.
Illustrative, not data: the shape of an acute suicidal crisis as described by survivors. About half report ten minutes or less between deciding and acting2,6. Slowing that window is the logic behind nearly every intervention below.

Ambivalent. Almost everyone in that state is of two minds. Part of them wants the pain to stop; part of them wants to live and can't see how. When you ask, you are talking to the second part. It is nearly always there.

Survivable. About nine in ten people who survive a suicide attempt never go on to die by suicide — roughly 7% over the following decade in the largest systematic reviews3,4. The crisis is not who they are. It is a moment they are in.

The story we tell about suicide — inevitable, secret, unstoppable — is mostly wrong. That is good news, because it means there is a lot we can do.

The numbers, briefly

In 2024 a little over 48,800 Americans died by suicide, about 13.7 per 100,000 — a modest decline from the record-high years of 2021–2023, but still among the highest levels ever recorded1. Rates fell for people in their late twenties and early thirties; they did not fall in the Mountain West, where I live and practice1. Utah has sat in the top ten states for suicide for as long as I have been a doctor8.

For every death, an estimated 135 people are touched — family, friends, classmates, coworkers, clinicians5. That is millions of us every year. If you are reading this because you have lost someone, I am so sorry. Nothing here is meant as a verdict on what you did or didn't see. Hindsight makes patterns visible that were invisible in the moment, to everyone.

One more number that reframes the whole problem: in the CDC's analysis of 27 states, 54% of people who died by suicide had no known mental-health condition at the time of death9. Not "no condition" — no known one. Most were never seen.

What I learned from the Utah Youth Suicide Study

Early in my training at the University of Utah I joined a team led by Douglas Gray, MD, on a study he had started years earlier: the Utah Youth Suicide Study10,11. Utah is one of only a handful of states with a centralized medical examiner, which made something rare possible — a near-complete look at every youth suicide in the state over several years, with toxicology, records, and long interviews with the people who had known them: parents, best friends, teachers, clergy. We went on to collect DNA samples from more than a thousand people who had died by suicide, for a genetics study, and our group later ran a database study of roughly 2,000 suicides in the Intermountain health system.

Some of what we found still shapes how we think about prevention:

Utah Youth Suicide Study, ages 13–21. Diagnosis and treatment from psychological autopsy (n=49 in-depth cases)11; prescription and toxicology from the medical-examiner series (n=151)10,12. The illness was usually there. The treatment — and the medication — almost never was.

Suicide, we learned, is rarely one cause. It is a convergence — genetics (close relatives of someone who died carry roughly three times the risk16,17), illness, substance use, loss, isolation, access to means, and a moment. You cannot fix all of it. You only have to interrupt the convergence once.

How to check in on someone

This is the part most people are afraid of, so let's be concrete. The evidence is clear on the fear that stops most of us: asking someone directly about suicide does not plant the idea or increase risk. A systematic review of the studies that tested this found no harm and, if anything, some relief18; a randomized trial of 2,342 high-school students found that screening questions about suicide caused no increase in distress or suicidal thinking, including among the highest-risk students19. In my experience, the more common reaction to being asked is a kind of exhale: someone finally noticed.

Myth or fact? · tap to reveal
Asking someone if they're suicidal can put the idea in their head.
Myth. Systematic review and a 2,342-student randomized trial: asking causes no increase in suicidal thinking or distress18,19.
People who talk about suicide are just seeking attention and won't act.
Myth. Talking about death, feeling trapped, or being a burden are recognized warning signs20. Take it seriously every time.
Once someone is suicidal, they'll always be suicidal.
Myth. About nine in ten people who survive an attempt never die by suicide3,4.
Most people who die by suicide saw a doctor in the months before.
Fact. About 83% had a healthcare visit in the prior year and roughly half in the prior month, often for something physical21,22.
Most people who die by suicide were on antidepressants.
Myth. In Utah and New York youth autopsy series, about 3% had any psychiatric medication in their blood10,14. The overwhelming majority were untreated.
A short caring text message from someone who noticed can reduce suicide attempts.
Fact. Caring letters reduced deaths in a randomized trial23; caring texts reduced attempts among service members24.

What to watch for

These are the consensus warning signs from the American Association of Suicidology's expert panel20:

Talk

Feeling trapped, being a burden, unbearable pain, having no reason to live, saying goodbye, "you'd be better off without me."

Behavior

Withdrawing from people and things they loved, giving things away, sleeping far more or far less, using more alcohol or drugs, sudden calm after a long stretch of despair, researching ways to die.

Mood

Hopelessness, agitation, rage, humiliation, or a flatness that looks like nothing is left.

Context

A recent loss, breakup, legal trouble, job loss, a suicide in their circle, or a hospital discharge — the suicide rate in the first three months after psychiatric discharge is roughly 100 times the general population's25.

None of these means someone is suicidal. A cluster of them, in someone who seems changed, is your cue.

What to say

"I've noticed you've seemed really down lately, and I've been thinking about you. How are you, actually?" — then be quiet and let them answer.

"Sometimes when people are hurting this much, they think about suicide. Are you thinking about suicide?" — direct, plain words. Not "hurting yourself," not "doing something stupid." The word itself.

"Thank you for telling me. I'm really glad you did. I'm not going anywhere." — you don't have to fix it. Presence is the intervention.

"How do you hurt? How can I help?" — two of the best questions I know.

"Let's call 988 together," or "Can I sit with you while you text them?" — you are not handing them off. You are bringing in help while staying.

"You've seemed really weighed down. I'm not here to lecture — I just want to understand what it's like for you right now." — side by side (a drive, a walk) is easier than face to face.

"Some kids who feel this way think about suicide. Have you?" — the same plain word. Teens can smell a euphemism.

"I'm glad you told me. You're not in trouble. We're going to figure this out together, and I'm going to check in on you a lot — that's not me hovering, that's me loving you." — name the follow-up so it doesn't feel like surveillance.

"Is there stuff in the house that would make a bad night more dangerous? Let's put it somewhere it can't be reached." — done with them, not to them; 988 can walk you through the specifics.

"Got a minute? Somewhere private?" — never at their desk, never in a group.

"I don't want to overstep, but you haven't seemed like yourself, and I care about how you're doing. How are things — really?"

"When things pile up like this, some people start thinking about suicide. Is that happening for you?" — you are allowed to ask. You are a human being before you are a colleague.

"Thank you for trusting me. Can we call the EAP or 988 right now, together? I'll stay." — then tell your manager or HR what they need to know to keep the person safe — not the details, just that help is needed.

"I'm so glad you're home. How's it been since you got back?" — the weeks after discharge are the highest-risk window there is25.

"Do you have your safety plan handy? Can we look at it together?" — hospitals should send one home; if they didn't, make one below.

"When's your follow-up appointment? Can I drive you?" — an appointment within a week, with a human who checks that it happened, is itself an intervention.

"I'm going to text you every day this week — not to check up, just to say hi." — caring contacts, the intervention with the sweetest evidence base23,24.

Do
  • Ask directly, in private, and listen more than you talk18.
  • Take it seriously even if they laugh it off20.
  • Ask what they have thought about doing — and help put time and distance between them and it. A 988 counselor can walk you both through this specifically26.
  • Help them make a simple plan for the next 24 hours: who they'll be with, who they'll call27.
  • Follow up. Tomorrow. Next week. A text is enough23,24.
  • Say "died by suicide," not "committed suicide." Language carries stigma, and stigma keeps people quiet28,29.
Don't
  • Promise to keep it a secret. You can promise to be there; you can't promise silence.
  • Argue about the value of life, minimize ("but you have so much going for you"), or rush to advice.
  • Act shocked or angry. If they see fear in your face they will protect you by shutting down.
  • Assume someone else is reaching out. Usually no one is.
  • Leave someone alone if they tell you they are in danger right now.

Why the follow-up text matters more than you think

One of the most beautiful findings in this field is also one of the simplest. In the 1970s, Jerome Motto sent short, caring letters — we're thinking of you, we hope you're doing okay — to people who had declined treatment after a psychiatric hospitalization. Nothing else. Over the following years, the people who got the letters were significantly less likely to die by suicide23. Decades later, the US military ran the same experiment with text messages and saw fewer suicide attempts24. "Caring contacts" are now a recognized intervention. You can run one from your phone.

What actually works Evidence-graded

Two independent systematic reviews, a decade apart, reached the same conclusions about which strategies have the strongest evidence: reducing access to lethal means, treating the underlying illness, and — with growing support — brief, suicide-specific psychological interventions and follow-up30,31. Here is the toolkit, roughly in order of evidence strength.

The brief, crisis-facing interventions — things a person or clinician can start this week — and the reductions in suicidal behavior each reported versus comparison care. Different outcomes and populations, so read it as a map, not a ranking. Safety planning + follow-up: 45% fewer suicidal behaviors at 6 months27. Cognitive therapy for suicide prevention: 50% fewer reattempts at 18 months32. DBT: about half the attempt rate of expert non-behavioral therapy33. Brief CBT (military): 60% fewer attempts over 2 years34. Ketamine and the Zero Suicide health-system model each get their own section below.

Putting time and distance between a person and the means Strong

Because the crisis is brief, anything that slows a person down saves lives. This is the best-established finding in all of suicide prevention: when communities reduce easy access to the most lethal means, suicide rates fall — in the best-documented cases by a third to a half — and people largely do not switch to another method35,30,31. At the level of one household, this means asking a person what they've thought about and, with them, making it harder to reach in a bad hour26. Clinicians call this lethal-means counseling; you can call it love with a lockbox. 988 and your clinician can guide the specifics.

Safety planning Strong

A safety plan is a one-page, written, personal list made before a crisis: my warning signs; what I can do on my own to get through the next hour; people and places that distract me; people I can tell; professionals and 988; and how I'll make my environment safer. In a study of 1,640 emergency-room patients, a safety plan plus a couple of follow-up calls cut suicidal behavior by 45% over the next six months27; a meta-analysis of safety-planning-type interventions found they roughly halve the odds of suicidal behavior36. It takes twenty minutes. (A "no-suicide contract," by contrast — promising a clinician you won't — has no evidence behind it and can give everyone false comfort.) Make one right here:

My safety plan · Stanley–Brown format · stays on your device unless you copy or print it

Caring contacts and follow-up Good

The letters and texts above23,24. Also: making sure someone has an appointment within days, not weeks, of leaving a hospital or ER, and that a human checks whether they made it there — because the post-discharge window is when risk peaks25.

Suicide-specific psychotherapy Strong

Treating "depression" in general helps; therapies that target suicidal thinking directly help more. Cognitive therapy built for suicide prevention halved repeat attempts in a randomized trial32. Dialectical behavior therapy (DBT) halved attempts in people with chronic suicidality33, a result confirmed in meta-analysis37. Brief CBT for suicide prevention cut attempts by 60% in soldiers34, and CAMS (Collaborative Assessment and Management of Suicidality) reduced suicidal ideation faster than usual care38. If you are seeking therapy for suicidal thoughts, ask specifically for one of these.

Screening in ordinary healthcare Good

About 83% of people who die by suicide had a healthcare visit in the prior year and roughly half in the month before, often for something physical — a backache, insomnia, a stomach problem21,22. A four-question screen (the ASQ) takes 20 seconds and, in the NIMH's validation study, caught 97% of at-risk youth39. When I trained clinicians on this, I told them: if you only ask one question, make it "On a scale of 0 to 10, how much do you intend to take your life in the coming days?" The number is not the whole story, but it starts one. Health systems that build screening, safety planning and follow-up into every visit — the "Zero Suicide" model, pioneered at Henry Ford in Detroit — have reported reductions in patient suicide of 75% or more40.

Medications that reduce suicide risk Good

Ketamine and esketamine in a suicidal crisis Good, with limits

I should say where I stand: I founded Utah's first esketamine clinic and have spent years running ketamine treatment and research. I am not neutral about this medicine. So let me be careful and let the trials speak.

The problem ketamine addresses is the one that runs through this whole post. Every other antidepressant takes weeks. A person in acute crisis does not have weeks. Ketamine — an old anesthetic that blocks NMDA glutamate receptors and triggers a burst of synaptic growth — changes suicidal thinking on a timescale of hours.

What the controlled trials show. Top: individual-patient-data meta-analysis of 10 trials (n=298) — the share of participants with no suicidal ideation one day after a single IV dose42. Middle: the largest single trial, ketamine vs midazolam (an active placebo) in 80 people with major depression and suicidal thoughts — clinically meaningful response at day 144. Bottom: how the effect fades — Cohen's d versus control at day 1 and one week in the same meta-analysis42; a separate meta-analysis found the effect clearest in the first 72 hours45.
What it does

A single IV dose (0.5 mg/kg over 40 minutes) reduces suicidal ideation within hours; the effect is moderate to large at day 1 and still detectable, though smaller, at one week42,45. The reduction is partly independent of the improvement in depression — it seems to act on the suicidal thinking itself44.

What it doesn't do

No trial has been large or long enough to measure suicide deaths, and the FDA label for esketamine says plainly that effectiveness in preventing suicide has not been demonstrated46. The effect wanes over one to two weeks without repeated dosing or follow-on treatment45. It is a bridge, not a cure.

Esketamine (Spravato)

The nasal-spray form is FDA-approved for major depression with acute suicidal ideation or behavior, given with standard care in a certified clinic with two hours of monitoring46. In its two pivotal trials it beat placebo on depression at 24 hours — but not on the clinician-rated suicidality measure, because standard care (usually hospitalization) improved that in both groups47,48. That is a real limitation, honestly reported.

Where it fits

For someone in crisis: as a way to buy days of relief while a safety plan, a therapist and a longer-term treatment are put in place. Not instead of those. Watch for dissociation, a temporary rise in blood pressure, and — with prolonged frequent use — bladder problems and misuse; it should be given and monitored by a clinician, never sourced on your own.

My honest summary for a provider weighing it: ketamine is the only tool we have that reliably changes suicidal thinking on the timescale of a crisis, and that alone earns it a place. But the trials measured thoughts, over days. Its value depends entirely on what you build around it during the window it opens.

Zero Suicide: what a health system can do

In 2001, the behavioral-health division of the Henry Ford Health System in Detroit set a goal that most clinicians thought was naive: zero suicides among the patients in its care. They called it "Perfect Depression Care." Within four years, the suicide rate among their patients had fallen by about 75% — and in several subsequent years, it was zero40,49.

What they did was not exotic. It was the contents of this post, applied to every patient, every visit, without exception:

The caveats are real: Henry Ford's result is a before-and-after comparison in one system, not a randomized trial. But the model has since been replicated — an Australian health service that implemented the Zero Suicide framework saw a significant fall in repeat suicide attempts among its patients, in a much larger and more rigorous analysis50. It is now the national model in the US31. If you run a clinic, this is the blueprint. If you are a patient, it is what you should be able to expect — and can ask for.

Connection, purpose, and the things that aren't "treatments" Good

The most useful psychological model of suicide I know is Thomas Joiner's: the desire for death grows when a person feels they don't belong and that they are a burden, and the capability to act on it grows with exposure to pain and fear51. The model tells you where the levers are. Belonging — a text, a ride, a seat at the table — is not a soft intervention. It moves the variable that matters. So do stable housing, work, faith or a sense of purpose, caring for someone (children, a dog), and skills for riding out emotion. These are the protective factors the CDC lists in every study that has looked52.

"I don't belong" thwarted belongingness "I'm a burden" perceived burdensomeness desire capability habituation to pain and fear highest risk Where you can push: belonging ↑ · burden ↓ access to means ↓
The interpersonal theory of suicide51. Desire arises where "I don't belong" and "I'm a burden" overlap; an attempt requires the added capability to act. Every lever a friend has — a text, a ride, a locked drawer — pushes on one of the three circles.

The SSRI question, honestly

I need to talk about antidepressants, because a lot of people are frightened about them right now, and frightened people make decisions in the dark.

In May 2026 the Department of Health and Human Services launched a "MAHA action plan to curb psychiatric overprescribing," with new payment codes for deprescribing, federal training on prescribing risks, and mandatory informed-consent language53. Its architects have claimed, in various public settings, that SSRIs are "harmful," "harder to quit than heroin"54,55, and even linked to mass shootings56. I want to separate what is right in that message from what is not, because both parts matter for keeping people alive.

The claimAmericans are overmedicated; too many people are on antidepressants.
What the evidence saysPartly fair. About 13% of US adults — roughly one in eight — took an antidepressant in 2015–18, and use has risen for two decades57. For mild depression the drug–placebo difference is small58; psychotherapy, exercise, sleep and light are under-offered. But "too many" is a judgment, not a measurement — and 54% of people who die by suicide had no known diagnosis at all9. Under-treatment and over-treatment coexist.
The claimSSRIs are "harder to quit than heroin."
What the evidence saysDiscontinuation is real; the comparison is not. The best meta-analysis finds about 15% of people stopping an antidepressant have symptoms attributable to the drug, and about one in thirty-five have severe ones59 — higher than older guidelines admitted60, and a reason to taper slowly61. There is no craving, no dose escalation, no compulsive use; it is not addiction. Careful deprescribing is legitimate medicine that deserves to be paid for.
The claimSSRIs cause mass shootings.
What the evidence saysNo evidentiary basis. The researchers who maintain the largest database of US mass shooters have found no causal link, and most perpetrators had no record of psychiatric medication62. Serious mental illness itself accounts for only about 4% of interpersonal violence in the United States63. People with mental illness are far more likely to be victims than perpetrators.
The claimSSRIs are the problem behind suicide.
What the evidence saysThe data say nearly the opposite. Autopsy series in Utah and New York found only ~3% of youth who died had any psychiatric medication in their blood10,14; Swedish national data found the same low detection rates in adults15. Across countries and US counties, rising antidepressant use tracked with falling suicide rates64,65,15. The population that dies by suicide is, overwhelmingly, untreated.

So what is true about SSRIs and suicidal thoughts?

Here is the whole picture, as fairly as I can give it.

Left: the FDA's pooled pediatric trials behind the 2004 boxed warning — suicidal thoughts or behaviors in about 4% on antidepressant vs 2% on placebo; no suicide deaths in those trials66. Right: the same signal across ages in the FDA's adult analysis — odds ratios for suicidality by age band: under 25, 1.62; 25–64, 0.79; 65 and older, 0.3767. Below 25 the risk rises; above 65 the drug is protective.
After the 2004 boxed warning: change in antidepressant use and in psychotropic-drug poisonings (a proxy for suicide attempts) among 1.1 million adolescents and 1.4 million young adults in 11 US health plans, 2000–201073. Completed suicides did not change in the same data — which is exactly why the authors called the poisonings a warning, not a verdict.
The bottom line on SSRIs

They are modestly effective medicines58, overprescribed to some and under-offered to others, with a real but small early-treatment risk of increased suicidal thinking in people under 2566,67 that is managed by close follow-up69,70. They are not the cause of the suicide epidemic10,14,15. Untreated illness is far closer to it9,11. Both of those things can be true at once, and a good clinician holds both.

Rallying together

Nearly everything in this post is something an ordinary person can do. Here is the list I'd hand you if we were sitting across a table.

  1. Learn the signs, and ask. Directly, with the word18,20. Today, if there's someone you've been wondering about.
  2. Put 988 in your phone and tell three people it exists. It launched in 2022 and too few people know it.
  3. Take a two-hour course. QPR (Question, Persuade, Refer) or Mental Health First Aid. Utah's Live On campaign offers free training. You'll never regret knowing what to do.
  4. Make your home safer — for a family member in a hard season, or for the teenager who lives there. Time and distance26,35. A locked drawer costs twenty dollars.
  5. Follow up. The person who scared you last month — text them now23,24. The people who "seem fine" after a hospitalization or a loss — those are the ones25.
  6. Change your language. "Died by suicide." It sounds small. It isn't28.
  7. If you're a clinician: screen everyone39, safety-plan everyone who screens positive27, know the treatments above, and see young people back within a week or two of starting or changing a medicine69.
  8. If you've been thinking about it yourself: tell one person, today. Make a safety plan with them — the builder above works. Call 988 while they sit with you. You are in a moment, not a sentence — and the numbers, for once, are on your side3,4.
"Always remember that melancholia is a misfortune, not a fault."Abraham Lincoln — who knew the dark well, and lived78

People don't choose mental illness. They also, far more often than the old story admits, survive it. Let's make sure they have the chance.

— Reid

Sources

  1. Curtin SC, Garnett MF. Provisional suicide deaths in the United States, 2024. NCHS Vital Statistics Rapid Release, December 2025. Centers for Disease Control and Prevention.
  2. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19–24.
  3. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry. 2002;181:193–199.
  4. Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS One. 2014;9(2):e89944.
  5. Cerel J, Brown MM, Maple M, et al. How many people are exposed to suicide? Not six. Suicide Life Threat Behav. 2019;49(2):529–534.
  6. Simon TR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(1 Suppl):49–59.
  7. Shneidman ES. Suicide as psychache. J Nerv Ment Dis. 1993;181(3):145–147.
  8. American Foundation for Suicide Prevention. Suicide statistics (state data). afsp.org/suicide-statistics, accessed September 2026.
  9. Stone DM, Simon TR, Fowler KA, et al. Vital Signs: trends in state suicide rates — United States, 1999–2016 and circumstances contributing to suicide — 27 states, 2015. MMWR. 2018;67(22):617–624.
  10. Gray D, Achilles J, Keller T, et al. Utah youth suicide study, phase I: government agency contact before death. J Am Acad Child Adolesc Psychiatry. 2002;41(4):427–434.
  11. Moskos M, Olson L, Halbern S, Keller T, Gray D. Utah youth suicide study: psychological autopsy. Suicide Life Threat Behav. 2005;35(5):536–546.
  12. Callor WB, Petersen E, Gray D, Grey T, Lamoreaux T, Bennett PJ. Preliminary findings of noncompliance with psychotropic medication and prevalence of methamphetamine intoxication associated with suicide completion. Crisis. 2005;26(2):78–84.
  13. Moskos MA, Olson L, Halbern SR, Gray D. Utah youth suicide study: barriers to mental health treatment for adolescents. Suicide Life Threat Behav. 2007;37(2):179–186.
  14. Leon AC, Marzuk PM, Tardiff K, et al. Antidepressants and youth suicide in New York City, 1999–2002. J Am Acad Child Adolesc Psychiatry. 2006;45(9):1054–1058.
  15. Isacsson G, Rich CL, Jureidini J, Raven M. The increased use of antidepressants has contributed to the worldwide reduction in suicide rates. Br J Psychiatry. 2010;196(6):429–433.
  16. Baldessarini RJ, Hennen J. Genetics of suicide: an overview. Harv Rev Psychiatry. 2004;12(1):1–13.
  17. Brent DA, Bridge J, Johnson BA, Connolly J. Suicidal behavior runs in families: a controlled family study of adolescent suicide victims. Arch Gen Psychiatry. 1996;53(12):1145–1152.
  18. Dazzi T, Gribble R, Wessely S, Fear NT. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychol Med. 2014;44(16):3361–3363.
  19. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005;293(13):1635–1643.
  20. Rudd MD, Berman AL, Joiner TE, et al. Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav. 2006;36(3):255–262.
  21. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6):870–877.
  22. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159(6):909–916.
  23. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv. 2001;52(6):828–833.
  24. Comtois KA, Kerbrat AH, DeCou CR, et al. Effect of augmenting standard care for military personnel with brief caring text messages for suicide prevention: a randomized clinical trial. JAMA Psychiatry. 2019;76(5):474–483.
  25. Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(7):694–702.
  26. Barber CW, Miller MJ. Reducing a suicidal person's access to lethal means of suicide: a research agenda. Am J Prev Med. 2014;47(3 Suppl 2):S264–S272.
  27. Stanley B, Brown GK, Brenner LA, et al. Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75(9):894–900.
  28. Recommendations for Reporting on Suicide (developed by AFSP, the National Action Alliance, SAVE, and journalism and public-health partners). reportingonsuicide.org.
  29. National Action Alliance for Suicide Prevention. Framework for Successful Messaging. suicidepreventionmessaging.org.
  30. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064–2074.
  31. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646–659.
  32. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563–570.
  33. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757–766.
  34. Rudd MD, Bryan CJ, Wertenberger EG, et al. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015;172(5):441–449.
  35. Yip PSF, Caine E, Yousuf S, Chang SS, Wu KC, Chen YY. Means restriction for suicide prevention. Lancet. 2012;379(9834):2393–2399.
  36. Nuij C, van Ballegooijen W, de Beurs D, et al. Safety planning-type interventions for suicide prevention: meta-analysis. Br J Psychiatry. 2021;219(2):419–426.
  37. DeCou CR, Comtois KA, Landes SJ. Dialectical behavior therapy is effective for the treatment of suicidal behavior: a meta-analysis. Behav Ther. 2019;50(1):60–72.
  38. Jobes DA, Comtois KA, Gutierrez PM, et al. A randomized controlled trial of the Collaborative Assessment and Management of Suicidality versus enhanced care as usual with suicidal soldiers. Psychiatry. 2017;80(4):339–356.
  39. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170–1176.
  40. Coffey CE. Building a system of perfect depression care in behavioral health. Jt Comm J Qual Patient Saf. 2007;33(4):193–199.
  41. Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ. 2013;346:f3646.
  42. Wilkinson ST, Ballard ED, Bloch MH, et al. The effect of a single dose of intravenous ketamine on suicidal ideation: a systematic review and individual participant data meta-analysis. Am J Psychiatry. 2018;175(2):150–158.
  43. Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003;60(1):82–91.
  44. Grunebaum MF, Galfalvy HC, Choo TH, et al. Ketamine for rapid reduction of suicidal thoughts in major depression: a midazolam-controlled randomized clinical trial. Am J Psychiatry. 2018;175(4):327–335.
  45. Witt K, Potts J, Hubers A, et al. Ketamine for suicidal ideation in adults with psychiatric disorders: a systematic review and meta-analysis of treatment trials. Aust N Z J Psychiatry. 2020;54(1):29–45.
  46. US Food and Drug Administration. SPRAVATO (esketamine) nasal spray prescribing information — indication for depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior (approved August 2020); label notes effectiveness in preventing suicide or reducing suicidal ideation has not been demonstrated.
  47. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). J Clin Psychiatry. 2020;81(3):19m13191.
  48. Ionescu DF, Fu DJ, Qiu X, et al. Esketamine nasal spray for rapid reduction of depressive symptoms in patients with major depressive disorder who have active suicide ideation with intent: results of a phase 3, double-blind, randomized study (ASPIRE II). Int J Neuropsychopharmacol. 2021;24(1):22–31.
  49. Coffey MJ, Coffey CE, Ahmedani BK. Suicide in a health maintenance organization population. JAMA Psychiatry. 2015;72(3):294–296.
  50. Stapelberg NJC, Sveticic J, Hughes I, et al. Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses. Br J Psychiatry. 2021;219(2):427–436.
  51. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575–600.
  52. Centers for Disease Control and Prevention. Risk and protective factors for suicide. cdc.gov/suicide/risk-factors, accessed September 2026.
  53. US Department of Health and Human Services. HHS launches MAHA action plan to curb psychiatric overprescribing. Press release, May 6, 2026.
  54. US Senate Committee on Health, Education, Labor and Pensions. Confirmation hearing of Robert F. Kennedy Jr., January 29, 2025 (transcript: "harder to quit than heroin" remark on SSRIs).
  55. Kennedy's SSRI rhetoric fuels distrust amid teen mental health crisis. STAT News, January 7, 2026.
  56. The complicated debate over MAHA's attack on SSRIs. The Week, May 22, 2026.
  57. Brody DJ, Gu Q. Antidepressant use among adults: United States, 2015–2018. NCHS Data Brief No. 377. National Center for Health Statistics, 2020.
  58. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391(10128):1357–1366.
  59. Henssler J, Schmidt Y, Schmidt U, Schwarzer G, Bschor T, Baethge C. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry. 2024;11(7):526–535.
  60. Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: are guidelines evidence-based? Addict Behav. 2019;97:111–121.
  61. Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry. 2019;6(6):538–546.
  62. Peterson J, Densley J. The Violence Project: How to Stop a Mass Shooting Epidemic. Abrams Press, 2021; and The Violence Project mass shooter database (theviolenceproject.org).
  63. Swanson JW, McGinty EE, Fazel S, Mays VM. Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Ann Epidemiol. 2015;25(5):366–376.
  64. Ludwig J, Marcotte DE, Norberg K. Anti-depressants and suicide. J Health Econ. 2009;28(3):659–676.
  65. Gibbons RD, Hur K, Bhaumik DK, Mann JJ. The relationship between antidepressant medication use and rate of suicide. Arch Gen Psychiatry. 2005;62(2):165–172.
  66. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63(3):332–339.
  67. Stone M, Laughren T, Jones ML, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ. 2009;339:b2880.
  68. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297(15):1683–1696.
  69. Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA. 2004;292(3):338–343.
  70. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006;163(1):41–47.
  71. Gibbons RD, Brown CH, Hur K, Davis JM, Mann JJ. Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. Arch Gen Psychiatry. 2012;69(6):580–587.
  72. March J, Silva S, Petrycki S, et al. (Treatment for Adolescents With Depression Study Team). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression. JAMA. 2004;292(7):807–820.
  73. Lu CY, Zhang F, Lakoma MD, et al. Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study. BMJ. 2014;348:g3596.
  74. Gibbons RD, Brown CH, Hur K, et al. Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry. 2007;164(9):1356–1363.
  75. Friedman RA. Antidepressants' black-box warning — 10 years later. N Engl J Med. 2014;371(18):1666–1668.
  76. Hengartner MP, Plöderl M. Newer-generation antidepressants and suicide risk in randomized controlled trials: a re-analysis of the FDA database. Psychother Psychosom. 2019;88(4):247–248. (The dissenting analysis; see Kaminski JA, Bschor T, Psychother Psychosom 2020;89(1):58–59 for the response.)
  77. Lewis G, Marston L, Duffy L, et al. Maintenance or discontinuation of antidepressants in primary care. N Engl J Med. 2021;385(14):1257–1267.
  78. Shenk JW. Lincoln's Melancholy: How Depression Challenged a President and Fueled His Greatness. Houghton Mifflin, 2005.

This post is educational and is not medical advice or a substitute for care. It is written to the Recommendations for Reporting on Suicide and the National Action Alliance's Framework for Successful Messaging: no methods, no simplistic causes, always a way to help. If something here stirred something up: 988.