Coping With Suicidal Thoughts: A Survey of Personal Experience

Suicide is the tenth-ranked cause of death in the United States, accounting for nearly 40,000 deaths per year (1). Nonfatal suicide attempts result in approximately 700,000 emergency department visits in the United States annually (2). Approximately 4% of U.S. adults (and 7% of those under age 25) reported experiencing thoughts of suicide or self-harm in a 12-month period (3).

Of U.S. residents who reported experiencing suicidal thoughts, only half reported receiving care from specialty mental health providers (4,5). One-third reported receiving care from general medical providers, and one-quarter reported help from human service providers or other nonmedical sources (5,6). For many people who experienced thoughts of suicide, the primary or sole sources of support were community resources, nonprofessional helpers, and self-care (7).

The Depression and Bipolar Support Alliance (DBSA) conducted an informal online survey to describe use of various health and human services as well as use of specific self-care strategies by people who have experienced suicidal thoughts. The survey aimed to examine prevalence of using various sources of support and users’ perceptions of helpfulness of each.

Methods

DBSA is an educational, advocacy, and support organization for people living with mood disorders; the organization is governed, staffed, and run primarily by people with lived experience of depression and bipolar disorder. DBSA’s outreach activities include periodic constituent surveys regarding affected individuals’ and family members’ views regarding clinical, research, and policy issues. These surveys are available on the DBSA Web site, DBSAlliance.org; advertised via DBSA’s electronic newsletters for constituents and chapter leaders; and highlighted via DBSA’s social media channels. All surveys are anonymous; respondents are not asked to provide any identifying information.

A survey regarding individuals’ personal experience of coping with suicidal thoughts was posted on the Web site and the other outlets from February 28 through May 28, 2013. Topics within the survey include personal experience with suicidal ideation and behavior, experiences with sources of care or support regarding suicidal ideation, experience with personal self-care or wellness strategies, and attitudes regarding suicide prevention. Survey items were developed collaboratively by DBSA staff, individuals with lived experience of suicidal ideation, and mental health researchers. Questions regarding specific sources of support and self-care strategies include both Likert-type ratings of helpfulness and open-ended questions with space for comments. [The complete survey text is provided in the online supplement to this report.]

All respondents were advised about the goals and content of the survey, including our intent to publish survey results. Because all responses were anonymous and no protected health information was collected, written informed consent was not required.

Results

Of 611 survey respondents, 588 (96%) reported ever having “thoughts about harming yourself or killing yourself,” 460 (75%) reported ever having “made a plan to harm yourself or try to kill yourself,” 293 (48%) reported ever having “done something to try to kill yourself,” 315 (52%) reported ever having been “admitted to a hospital because of suicidal thoughts or a suicide attempt,” and 203 (33%) reported ever having been “held or treated against your will because of suicidal thoughts or a suicide attempt.” Subsequent results were limited to the 588 respondents who reported a history of suicidal thoughts. [Results for the full sample are in the online supplement.]

Questions and responses regarding use of various sources of help or support are shown in Table 1. The most commonly reported sources of help for suicidal thoughts were mental health professionals (therapists and psychiatrists) and family members. Use of peer support was also frequent, with three out of four receiving individual support from speaking with peers, over half attending an in-person peer support group, and about one-third receiving online peer support. One-half reported ever seeking help from an emergency department because of suicidal thoughts, and only one-third reported ever calling a crisis line.

Also shown in the upper portion of Table 1 are responses regarding perceived helpfulness of each source of support. Ratings of helpfulness were limited to those reporting some use of that service or resource. Respondents’ experiences varied considerably, with every resource being described as very helpful by a significant proportion and every resource being described as harmful by at least a few. Interactions with therapists or psychiatrists were described most favorably, with over 80% of respondents describing those interactions as somewhat or very helpful. Various types of support from peers (individually, in support groups, or online) were described as somewhat or very helpful by 65%−80% of respondents. Respondents’ experiences with emergency rooms and telephone crisis clinics were more mixed, with approximately half reporting those encounters as somewhat or very helpful but 10%−15% describing them as harmful. Experiences with support from family members or clergy were similarly mixed. Respondents’ free-text comments (online supplement) illustrate the diversity of experience with different sources of support.

Additional analyses examined perceived helpfulness according to personal history of suicide attempt (online supplement). Talking with primary care physicians was rated as not helpful or as harmful by 49% (N=99) of those with a history of suicide attempt, compared with 29% (N=50) of those without a suicide attempt. Talking with family members regarding suicidal thoughts was rated as not helpful or harmful by 57% (N=133) of those with a personal history of suicide attempt compared with 40% (N=87) of those without such history. Helpfulness ratings for other services or resources did not differ between those with and without a history of suicide attempt.

Questions and responses regarding use of various self-care strategies are also shown in Table 1. Over 80% of respondents reported some experience with positive self-talk; prayer or meditation; social contact; physical activity; scheduling activities to stay busy; or distraction by movies, television, or other entertainment. Nearly two-thirds reported ever having used alcohol or street drugs to attempt to manage suicidal thoughts.

Also shown in Table 1 are responses regarding perceived helpfulness of various self-care strategies. Most self-care strategies were described as somewhat or very helpful by 70% or more of respondents. Prayer or meditation was most often rated as very helpful—by nearly one-third of survey participants. In contrast, use of alcohol or street drugs was infrequently reported as helpful and was experienced as harmful by over 40%. Taking extra medication to cope with suicidal thoughts was reported as very helpful by about one in five respondents and as harmful by an approximately equal number. Free-text comments (online supplement) illustrate the diversity of experience with various self-care strategies.

Additional analyses examined perceived helpfulness of self-care strategies according to personal history of suicide attempt (online supplement). Respondents with a personal history of suicide attempt were more likely than those without such a history to report that using extra medication to manage suicidal thoughts was not helpful or was harmful (45%, N=106, versus 30%, N=59). Perceived helpfulness of other self-care strategies did not vary according to personal history of suicide attempt.

When asked about attitudes toward suicide prevention, 73% (N=441) of respondents somewhat or strongly agreed with the statement that suicide is often preventable. Whereas 72% (N=435) somewhat or strongly agreed that involuntary treatment is sometimes necessary, 52% (N=313) somewhat or strongly endorsed being reluctant to speak with health care providers about suicidal ideation. Opinions regarding preventability of suicide, willingness to speak with providers about suicidal thoughts, and appropriateness of involuntary treatment did not differ significantly between respondents with and without a personal history of either a suicide attempt or involuntary treatment (online supplement).

Discussion

The methods of this survey (anonymous responses to a broad public invitation) resulted in important limitations. For example, we were not able to describe respondents’ demographic characteristics, diagnoses, or histories of treatment. We could not determine the number of people reached by survey invitations or the proportion of those reached who responded. Consequently, we could not assess representativeness of this sample compared with all people living with mood disorders or all people who experience suicidal thoughts. Compared with previous community surveys regarding suicidal thoughts (4,5), in our survey respondents were more likely to report use of specialty mental care. Likelihood of responding to the survey may have been related to past experiences; those who were especially satisfied or especially dissatisfied with specific services may have been more likely to respond.

Despite the limitations, these data provide a unique view of the experiences and views of people who have experienced suicidal thoughts or attempted suicide. We are not aware of other data regarding the use and perceived helpfulness of the full range of professional services, community services, and self-care for people experiencing thoughts of suicide or self-harm.

In combination with population-based data from other sources (4–6), these survey findings have implications for suicide prevention efforts across a range of health care and human service settings. Although respondents to our surveys typically reported positive experiences with specialty mental health providers, only half of community residents experiencing suicidal ideation (and half of people who die by suicide) receive specialty mental health care (4,8). A larger proportion of people experiencing suicidal ideation see general medical providers for help (5,6), but our survey respondents reported such contacts as only moderately helpful. Improving the quality or helpfulness of suicide prevention services in general medical settings appears to be a priority.

Our survey findings also suggest that additional attention needs to be devoted to experiences with emergency resources. Our respondents reported relatively low utilization of emergency departments and telephone crisis clinics, the expected sources of round-the-clock emergency care for suicide risk. In addition, those emergency resources were among the services most often rated as unhelpful or harmful. This higher rate of negative experiences may reflect the circumstances in which individuals often encounter these services: an urgent or crisis situation in which people may fear coercive or involuntary treatment. A 2009 survey of users of a suicide prevention helpline found generally high rates of satisfaction (9). Nevertheless, the increased frequency of negative ratings for emergency or crisis service settings suggests a need to reconsider how these services might collaborate more with people in crisis. A survey of emergency department providers (10) identified a need for additional training regarding assessment of and counseling and referral for people with suicidal thoughts. Addressing consumers’ negative perceptions of existing emergency services may require additional training for emergency care providers or increased availability of alternative emergency care resources, including respite services and peer-provided services.

Services most frequently used were among those described as most helpful, and those least often used were rated less favorably. The exceptions to this pattern were support from family members and peer support services (both peer support group and online peer support). Support from family members was often used but also had relatively high prevalence of unfavorable experiences. Conversely, peer support services were used by less than half of those responding but were among the most favorably rated by our survey respondents. This combination of relatively infrequent use and high rates of perceived helpfulness suggests a missed opportunity: increasing awareness and availability of organized peer support resources could have significant benefit for people who experience suicidal thoughts.

Self-care activities appear to be the most common strategies for dealing with suicidal thoughts. This finding is consistent with Alexander and colleagues’ (7) previous assessment of lived experience of suicidal ideation. High rates of utilization and high ratings for helpfulness of prayer or meditation were notable. Spirituality or religious practice are not emphasized by most structured psychotherapies for mood disorders or by therapies specifically developed to manage suicidal ideation. Our findings suggest that mental health and human service providers may want to ask people presenting with suicidal ideation about their use of a variety of spiritual practices. Our data suggest that meditation, prayer, and other personal spiritual practices can be helpful self-care tools for a significant proportion of people coping with suicidal thoughts. Although personal spiritual practices were often rated as helpful, it is notable that talking with clergy or other spiritual advisers received relatively low ratings for helpfulness.

Also of note were high rates of use and high ratings for helpfulness of various activities to distract attention from suicidal thoughts (exercise, social contact, and entertainment, for example). Providers should consider these strategies as potentially useful parts of self-care or crisis management plans.

Use of extra medication was often rated unfavorably (second only to use of alcohol and street drugs). We cannot determine, however, whether respondents were describing provider-supervised use of “rescue” medications or self-directed overuse of anxiolytic or sedative-hypnotic drugs.

Conclusions

Attitudes regarding suicide prevention revealed an important paradox. Over 70% of respondents agreed that suicide is often preventable, and a similar proportion agreed that involuntary or forced treatment is sometimes necessary. Nevertheless, over half indicated reluctance to speak with doctors or therapists regarding suicidal thoughts. Our survey did not address reasons for that reluctance. Understanding and addressing barriers to open communication regarding suicidal thoughts should be a priority for future research.