Paul Nestadt, MD, is the medical director of the Center for Suicide Prevention and the James Wah professor of psychiatry at Johns Hopkins School of Medicine in Baltimore.
When you’re caring for someone with depression, it’s important to know that the condition can lead to suicidal thoughts or attempts. In the U.S., depression is linked to about 40,000 suicides a year.
If your loved one hasn’t talked about or attempted suicide before, their behavior might offer clues that they’re having suicidal thoughts. Often, their depression might seem to become worse. If you notice that happening, think about having a candid talk with your loved one — it could be lifesaving, or it could simply show them how much you care.
We spoke with Paul Nestadt, MD, about how to start the conversation and what steps you can take to help your loved one stay safe. (If you think your loved one is in imminent danger of attempting suicide, call 911 or the 988 Suicide & Crisis Lifeline right away.)
Q: If you’re concerned that a loved one with depression might be thinking about suicide, how should you talk with them about it?
Nestadt: It’s important to directly ask them. Some people worry about a couple of things that I think are myths that I’d love to dispel. People worry that they might plant the idea of suicide in their loved one’s head. At Johns Hopkins, we talk to our medical students about that early on when they’re learning how to be psychiatrists. We say people aren’t that manipulable; if someone is not thinking about suicide, you suggesting it is not going to make them all of a sudden suicidal.
And if someone is thinking about suicide, you asking them directly can do a couple of positive things: One, they might be honest with you and say, “Yes, I am.” And that opens the door for you to start to help them navigate their way to getting help. Or they might not be honest with you; they might not want to talk about that right now. But what you’ve done by asking is you’ve opened the door, and you’ve basically said, “If you do at some point decide you want to talk, I’m here for you.”
Q: Are there any subtle clues that might mean your loved one is having suicidal thoughts and it’s time to start the conversation?
Nestadt: Yeah, a lot of those clues are also related to clues that their depression’s becoming more severe. There’s a lot of overlap there. Maybe you’re not seeing them as often. Or they’re not doing things that they like to do. You might see them using drugs or alcohol more than usual. They might also appear just outwardly less animated; they don’t make so much eye contact, or they’re not smiling as much.
Other clues could be that they’re sleeping less, or they’re eating less. They’re less energized. Maybe they say more derogatory things about themselves, indicating a poorer opinion of themselves. And often people with severe depression will say, “I’m feeling worse.” Not everybody does that, but you don’t want to be blind to the fact that someone might just come out and say, “Listen, I’m not feeling well.”
If you’re noticing those sorts of things, that’s when the door is open for you to say something like — “I’ve noticed that you seem more down, more withdrawn lately. I’m a little worried about you. Let’s talk about it a little bit.” And then eventually, that conversation might lead to — “Hey, I know that some people, when they start to feel this way, might even have thoughts about suicide. Are you having thoughts like that? I’m asking because I care about you. And if you’re having those thoughts, maybe we can find some help.”
Q: Is there an ideal place or time to have the conversation? Does the setting matter?
Nestadt: A lot depends on the specific situation and the person you’re talking to, but it would be ideal to have it when they have time to talk — not while they’re walking out the door. You want to have it in a setting where, ideally, you wouldn’t be interrupted. So, not in the middle of a large group talking. You want a good private space and, in a perfect world, you’d do it when they’re more relaxed. So, not when they’re in the middle of describing something terrible, like, “I’m so stressed right now.”
Q: If you can’t have the talk in person for some reason, what about by phone or video chat?
Nestadt: It might be a good idea early in that conversation, before things get real, to make sure you know where they are. Just in case it comes to the point where you need to call an ambulance or something, knowing where they are is helpful. You don’t have to ask in an interrogative way. Like if you’re on the phone, say, “Hey, where are you right now?” It just helps the conversation even, because you don’t know [much] if you’re just looking at them on the screen or on the phone.
I would also try to have an idea of, in the perfect world, someone who is nearby in case of an emergency [or] somebody who might be closer to them — so, their roommate’s number or their mom who lives in the neighborhood.
Q: If your loved one says they’ve been thinking about suicide, what are the next steps you can take to help them?
Nestadt: There’s a lot that you can do, but it really centers on two major themes. One is helping someone get into professional help. Because even though you might have their trust, you might not have the professional training to really address major depressive disorder, which might be behind the suicidality. It’s just sort of understanding that your role might be more about helping them get a therapist or a psychiatrist or helping them explain it to their primary care doctor.
You could also let them know about things like 988, our national crisis line. Not only can it sort of support somebody, but one really great function of 988 is that they can help someone find care. They’ll often know in your locality where there are therapists that can help. It’s also worth noting that a good chunk of calls to the National Crisis Line to 988 are not from the person who’s at risk themselves. They’re from a family member or a friend who wants advice.
You also want to make sure that your loved one is safe while waiting to get help. That might mean making sure there’s not [a thing] like a firearm in the house. Most suicide deaths in the U.S. are firearm suicides. In fact, most gun deaths are suicides, and most suicides are gun deaths.
Depending on what state you live in, there are different laws about what you’re able to do with someone’s gun as a loved one, as a family member, or a roommate or a friend or a spouse. First, suggest maybe: “Let’s get the gun. Why don’t you give me the key to your gun safe?” Or, “Let’s get you a gun safe.” Or, “Let’s get the gun out of the house.” A lot of states have what’s called a safe storage map where you can look up places that are willing to hold onto someone’s gun, no questions asked. It’s usually going to be shooting ranges or police stations or pawn shops that just hold the gun during a crisis.
And in some states — 22 states and D.C. — they have something called a red flag law or an extreme risk protection order law. These are laws that can be invoked by either the police or a loved one, family member, or a clinician, depending on the state. So if you’re worried someone might really be at risk [to] themselves or others by having access to a gun, you can petition to have that gun removed temporarily. In most states, it’s about a year, and the person is also put temporarily on the do not buy list. So, if they go to buy a gun, temporarily they can’t buy one.
You also might want to make sure your loved one hasn’t saved up their medications. Some people who’ve been thinking about attempting suicide by overdose start to stockpile their medications, like sleeping pills they’re prescribed or opiates. Consider asking them directly about that.
Q: When should you call 911 to get your loved one emergency help?
Nestadt: If the person seems really, really at risk — they say something like, “I actually think I’m going to kill myself tonight” — it’s an extreme situation. That’s when it might actually be appropriate to call 911 to get them to an emergency room [ER]. Suicide is often impulsive. When that suicidality strikes, it can be really overwhelming — and it’ll pass. You’ve just got to keep them safe until it passes. No one likes being rushed to the ER or being hospitalized, but forceful interventions can really save a life.
Q: What if your loved one admits they’ve had suicidal thoughts but tells you they’re not going to act on those thoughts?
Nestadt: They might at the moment be only having what we might call passive suicidal thoughts. Like, “I kind of don’t care if I live or die,” or like, “I’m not going to act on this now.” But that can very quickly turn into an active suicidal thought. They might not see it coming, but like if they’re living in the context of having these every once in a while or even chronic passive suicidal thoughts, all it might take is one bad day or two beers, and that can turn into an active suicidal plan, which can result in death.
So, when there’s passive suicidal thoughts, you don’t need to call 911 — but you should make a call to get your loved one into care. One thing that a loved one can convey to a person who’s struggling is that part of depression is a hopelessness and the sense that “this is just how it is for me.” And people need to recognize that depression, [or] major depressive disorder, is an illness that is so treatable. We’ve got amazing treatments — ranging from cognitive behavioral therapies, things like SSRIs [selective serotonin reuptake inhibitors], other antidepressants — that work really well. So, when someone is having passive suicidal thoughts, you can let them know — “Hey, this is actually really treatable. The illness itself makes you think that you are not treatable. You don’t need to feel this way.”
Q: Is there anything you shouldn’t say to your loved one when you’re talking with them about suicidal thoughts?
Nestadt: You don't want to minimize what they’re going through. One thing that sometimes happens that my patients have said they’ve been frustrated with when their loved ones have said it to them is, “I’ve been depressed, too. But you know what made me feel better? Getting some exercise or getting some fresh air.” So, the loved one is sort of misunderstanding major depressive disorder as sadness. And it can seem very dismissive to the person you’re speaking to.
You also don’t want to be saying things like — “Well, things could be worse. Think how lucky you are — you’ve got a great job, or you’ve got a great whatever.” That’s not what depression is really about. It’s not about their lives; they’re struggling with an illness.
You also don’t want to challenge them or minimize their suicidal thoughts with statements like — “You’re not gonna do that. You wouldn’t do that. You’re just being dramatic. You don’t really mean it.” That plays down what they’re really communicating to you.
You also have to watch out for promises of privacy. So, if they say something like, “I do want to talk to you. I have been feeling bad, but I need you to promise that it’ll stay between us,” or, “I need you to promise that you won’t tell anyone,” I would hesitate to promise that. Because if they then say something like, “Yes, I’m planning to kill myself,” or something else that really worries you, you don’t want to be in a position where then you’re deciding whether to betray that trust.
A good response to a request for privacy like that might be — “I’m happy to talk, just between us, but I have to tell you that I really worry about you, and I’m not a professional. And so, if it does seem like we need to get a professional involved, I’m going to really want to try to get you to care. But let’s talk about how you’re feeling.”
