Suicide is the tenth leading cause of death in the United States. On average, there are 123 suicides each day. There were more than twice as many suicides as there were homicides.

I treat many people in my practice who are clinically depressed, and most of those report some suicidal thoughts. Suicidal thinking or urges is one of the primary symptoms of the disease. While not every depressed person is suicidal, the risk should always be assessed.

Suicidal risk can be categorized according to severity. I try to determine which of the following descriptions best fit the person’s current state.

1. The depressed person has had some suicidal thoughts but has no plan for how he would do it. He just wishes he wasn’t here. He denies any intentions and can provide clear reasons as to why he wouldn’t do anything to himself.
2. The person denies any intention to act on it but has determined a plan of how she would do it if she actually made an attempt. The more lethal the plan, the more severe the risk. Plans involving firearms or hanging represent greater risk, especially if the person has such means available.
3. The person expresses uncertainty about his intentions. He can’t make a clear and believable no-suicide commitment. He often believes that his loved ones would be better off without him. He often sees suicide as a viable, and often the only, solution to the pain of his depression.

When I encounter a depressed person who expresses the belief that his suicide would have minimal impact on his loved ones, I ask him to do a little thought experiment. First, I have him think of someone he loves. I ask him to imagine that his cell phone rang at that moment in the session. I ask him to imagine that the caller was crying and having difficulty speaking. I then have him imagine that the caller told him that this loved one had committed suicide. I ask him how he would be impacted. I ask him how long it would take to get over that person’s suicide. I ask if he would have questions about what he could have done, or whether he might blame himself. I ask him if his life could ever be the same.

The response to the thought experiment is clear and often emotional. When we consider how a loved one’s suicide would impact us, we can see more accurately how our suicide would impact those we leave behind.

Suicide is always devastating to those left behind. Grief is compounded by questions, doubts, self-blame and often anger. Their lives are never the same. That’s the truth about suicide. Next week we’ll look at “The Lies of Suicide.”