Table 2: Warning Signs for Suicide: IS PATH WARM? Warning Sign Description Ideation Threats or talk of wish to hurt or kill self. Substance abuse Increasing alcohol or drug use. Purposelessness Expressing no reasons for living. Anxiety Agitation, restlessness, unable to sleep. Trapped Feeling that there is no way out. Hopelessness Self lacks value, others do not care, future is unchanging. Predisposing factors Although there are numerous risk factors for suicide, these are often presented without much context as to when the risk factor might occur or what kind of relationship they may have to an episode of suicidal behavior. By breaking down risk factors into specific types, clinicians, educators, and families can better understand the ways in which a specific factor might be connected to suicidal behavior, and how long before the suicidal behavior such a risk factor may occur. Risk factors for suicidal behavior can be divided into three types in terms of timing in relation to suicidal behavior: distal risk factors, proximal risk factors, and potentiating factors. Distal factors Distal risk factors are separated further in time from suicidal behavior, potentially having occurred months, years, or even decades before suicidal behavior. Distal factors are important because they create a statistical potential for suicidal ideation and behaviors; they set the stage for later problems with suicide, so to speak. Proximal factors Proximal factors refer to those risk factors that arise in close temporal proximity to acute suicidal behavior, meaning they are Biological risk factors for suicide can be both distal and proximal. Genetic factors, for example, are a distal risk factor arising at birth, and have been linked to suicide outcomes in large population-based studies (Erlangsen, Appradurai, Wang, Turecki, Mors, Werge, et al., 2018). However, it is important to note that the effects of any one genetic polymorphism on suicidal behavior are relatively small and no clear genetic combination has been found to have large effects in predicting suicidal behavior. Other biological distal factors can include abnormalities in neurotransmitter physiology, hormonal factors, and neurophysiological abnormalities (Turecki & Brent, 2016). Important proximal biological risk factors include suffering from physical illness, chronic pain, cancer, and/or a disability as near-term stressors that could precipitate a suicide crisis (Ferro, Rhodes, Kimber, Duncan, Boyle, et al., 2017; Henson, Brock, Charnock, et al., 2019; Lund, Nadorff, Winer, & Seader, 2016; Racine, 2018). Although biological risk factors likely play a role in the suicidal ideation and behavior of some patients, meta- analytic research has found that many biological links to suicidal behavior are relatively small (Chang et al., 2016), so while it is important to consider biological risk factors, suicide risk assessment and intervention should primarily focus on proximal biological risk factors (e.g., chronic pain or illness) as well as behavioral and psychosocial risk factors. Biological sex (i.e., for cis-gendered men versus women) is another important factor to consider, with men being more likely to die by suicide but with women attempting suicide far more often than men (Siegel & Rothman, 2016). Psychiatric diagnoses As has been previously discussed, aside from past suicide attempts, psychopathology is the most important predictor of suicide and is strongly associated with other forms of Distal factors Biological risk factors
Withdrawal
From friends, family members; sleeping all the time; anhedonia. Uncontrolled and excessive expressions of anger. Acting recklessly; high-risk behaviors. Dramatic shifts from typical mood state: ask to get more information.
Anger
Recklessness Mood changes
Note . Adapted from “Know the Warning Signs,” by the American Association of Suicidology, n.d. Retrieved from http://www.suicidology. org/resources/warning-signs
often viewed by others, family, or society as “triggering” events that spur acute (recent) suicidal behavior. Indeed, proximal factors can increase individual motivations for suicide, and proximal risk factors can also determine the timing of suicidal behavior by translating the statistical potential of distal risk factors into action (Franklin et al., 2016). Precipitating stressors or crises have substantial predictive value with respect to suicide attempts. Stressful life events have been found to have occurred for most individuals on the day they attempted suicide (Shen, Cunha, & Williams, 2016) or died by suicide (Howarth et al., 2020). Potentiating factors Potentiating factors represent a particularly powerful proximal risk factor, and typically involve the availability of lethal means (e.g., owning a gun, access to pills), recent or ongoing major stressors, illness, and so forth. Potentiating factors might be thought of as “triggers” for suicidal behavior, and often align with the warning signs for imminent suicidal behavior as previously discussed. Clinicians should be aware, however, that many patients will not be able to identify potentiating factors for their suicidal behavior. suicidal behavior. The vast majority (90 to 95%) of individuals who die by suicide have some diagnosable disorder at the time of death (Choi, Lee, & Han, 2020); it is likely that the fraction who did not were experiencing subclinical levels of psychopathology. Although most mental illnesses increase risk for death by suicide (APA, 2013), there are several disorders that are associated with particularly high risk. These include schizophrenia (approximately 13-fold increase in risk; Cassidy, Yang, Kapczinski, & Passos, 2018), anorexia nervosa (up to a 31-fold increase in risk; Selby & Coniglio, 2020), bipolar disorder (approximately 17- fold increase in risk; Olfson et al., 2016), major depressive disorder (approximately 20-fold increase in risk; Olfson et al., 2016), impulse- control disorders such as opioid use (approximately 14-fold increase in risk; Maruti et al., 2017), and personality disorders, especially borderline personality disorder (up to a 45-fold increase in risk; Soloff & Chiappetta, 2019). Retrospective interviews with informants, commonly referred to as psychological autopsies, have frequently been used to investigate the association between psychopathology and suicide and have consistently shown that roughly 90% of individuals who die by suicide had an identifiable psychiatric disorder before death (Perlis et al., 2016). Prior suicide attempts Approximately half of individuals who die by suicide do so after a single attempt (Franklin et al., 2016), which means that about 50% of individuals will die on their first attempt. A recent study on risk factors for death by suicide concluded that prior attempts and suicidal ideation were the best predictors of completed suicide (Ribeiro et al., 2016). However, it should be noted that prior attempts and suicidal ideation were relatively weak predictors, as they only increased risk for later death by suicide two-fold. Some research suggests that people who make multiple attempts (i.e., two or more) are at greater risk for further
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