If you read the news, you’ve seen an increase in stories about suicide over the past five years, which mirror increasing suicide rates among various age groups over the past twenty years, all of which may cause you to ask yourself the question we pose in the title of this article about the connection between psychotherapy and risk of suicide:
Is psychotherapy an effective way to reduce suicide risk?
That’s an important question to ask, and to have an answer to.
Why?
Because most of us assume that since suicide is – in most cases – related to mental illness and mental health disorders, and most of us also assume that treatment for mental health disorders that increase suicide risk includes psychotherapy as a primary component. However, it’s important for us to question our assumptions, and confirm that what we assume is true is actually true and verified by facts.
We know – based on evidence published in reputable, peer-reviewed scientific journals – the following mental health disorders increase suicide risk:
- Depression
- Anxiety
- Bipolar disorder
- PTSD/Trauma
- Schizophrenia
- Schizoaffective disorder
- Self-harm/non-suicidal self-injury (NSSI)
- Borderline personality disorder
- Obsessive-compulsive disorder
We also have verified facts and figures about suicide and suicidality through 2022, as reported by the Centers for Disease Control (CDC) in the report “Suicide Mortality in the United States, 2002–2022.” That report summarizes the developments that result in the news stories we see regularly in all forms of news media:
- 2002-2018: suicide rates for all age groups increased
- Males committed suicide at close to four times the rate of females
- 2018-2020: suicide rates decreased
- 2020-2022: suicide rates increased for most age groups, surpassing previous levels
- Rates for people 10-24 decreased from 2020-2022
- Among females in 2022, firearms were the leading means of suicide
- Among males in 2022, firearms were the leading means of suicide
That news is a mix of positive and not-so-positive: decreases for youth and young adult age groups, and relative increases for all others. This confirms the need for ongoing inquiry regarding effective treatment – such as psychotherapy – for people at elevated risk of suicide.
New Research: The Impact of Psychotherapy on Suicide
In 2024, a group of researchers published the article “Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis” that sought to answer this question:
“What are the effects of suicide-focused (direct) and other (indirect) psychotherapies on suicidal ideation and suicide attempts?”
To answer this question, the research team pooled the results of 147 studies including records from 11,000 patients with the following characteristics:
- Diagnosed with any mental health disorder
- Reported suicidal ideation
- Reported suicide attempts
- Engaged in direct psychotherapy
- Engaged in indirect psychotherapy
After collecting the data, researchers analyzed the sample set to determine whether engaging in direct psychotherapy or indirect psychotherapy had any impact on subsequent risk of suicidal ideation or suicide attempts. While most people know what psychotherapy is, most people have not heard of the distinction between direct psychotherapy and indirect psychotherapy.
We’ll explain that distinction now, using definitions provided by the American Psychological Association (APA) Dictionary of Psychology:
Direct Psychotherapy
This term is another way of saying typical psychotherapy. Here’s the APA definition:
“Psychotherapy is any psychological service provided by a trained professional that primarily uses forms of communication and interaction to assess, diagnose, and treat dysfunctional emotional reactions, ways of thinking, and behavior patterns. Psychotherapy may be provided to individuals, couples, families, or members of a group.”
In the context of this study, direct psychotherapy refers to psychotherapeutic approached designed to address suicidal behavior.
Indirect Psychotherapy
This is a form of psychotherapy or mental health intervention defined by the APA as follows:
“…a method of conducting therapy, particularly exemplified by client-centered therapy, in which the therapist does not attempt to direct the client’s communication or evaluate the client’s remarks, although they may refer back to the client’s remarks or restate them.”
In the context of this study, indirect psychotherapy refers to any psychotherapy for any mental health disorder that doesn’t focus directly on suicidality or refer explicitly to suicidal behavior.
We’ll share their results in a moment. First, we’ll look at the latest information we have on suicidality for 2023. The data in the report we share above included data collected by CDC researchers through 2022.
Suicide Facts and Figures: 2023
This data is available to the public in the 2023 National Survey on Drug Use and Health (2023 NSDUH), an annual, nationwide survey on health and mental health topics that includes data from over 70,000 survey respondents.
Here’s the data:
Suicidality Among Adults: 2023 NSDUH
Had serious thoughts of suicide in the past year, Adults 18+:
Total: 5% (12.8 million)
By Gender:
- Female: 5.5%
- Male: 4.5%
By Age:
- 18-25: 12.2%
- 26-49: 5.9%
- 50+: 2.1%
Made a suicide plan in the past year:
Total: 1.4%
By Gender:
- Female: 1.6%
- Male: 1.2%
By Age:
- 18-25: 4.2%
- 26-49: 1.6%
- 50+: 0.5%
Attempted suicide in the past year:
Total: 0.6%
By Gender:
- Female: 0.7%
- Male: 0.6%
By Age:
- 18-25: 2.0%
- 26-49: 0.6%
- 50+: 0.2%
Now let’s look at one more set of data, this time on suicide fatalities:
Suicide Fatalities, 2021-2023
2021 Total:
- 48,080
By Age:
- 10-24: 7,236
- 25-44: 16,724
- 45-64: 14,468
- 65+: 9,652
2022 Total:
- 49,437
By Age:
- 10-24: 6,529. Decrease of 8.4%
- 25-44: 16,843. Increase of 0.07%
- 45-64: 15,632. Increase of 6.6%
- 65+: 10,433. Increase of 8.1%
2023 Total:
- 49,380
*Final 2023 suicide fatality data by age group not yet available*
That data confirms the need for increasing our understanding of whether psychotherapy can reduce suicide risk: based on the significant increases between 2002 and 2022, with a dip between 2018 and 2020, we know suicide is not only a problem among youth, but also among all adult age categories.
Let’s take a look at the study we introduce in the beginning of this article.
Direct or Indirect Psychotherapy: Do They Reduce Suicide Risk?
As a reminder, the study looked at the impact of direct – specifically focused on suicidality – or indirect – not specifically focused on suicidality – psychotherapy on suicidal ideation and suicide attempts. While extensive literature exists on risk factors for suicidality and the impact of specific psychotherapeutic interventions on suicidality, such as cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT), the study authors indicate that:
“The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts.”
First, let’s look at the impact of direct and indirect psychotherapy on suicidal ideation:
- Patients who engaged in direct psychotherapy showed:
- An average 39% reduced instance of suicidal ideation
- Patients who engaged in indirect psychotherapy showed:
- An average 30% reduced instance of suicidal ideation
Next, let’s look at the impact of direct and indirect psychotherapy on suicide attempts:
- Patients who engaged in direct psychotherapy showed:
- An average 28% reduced risk of suicide attempts
- Patients who engaged in indirect psychotherapy showed:
- An average 32% reduced risk of suicide attempts
The results on suicidal ideation make sense. Therapy focused on suicidality reduces instances of suicidal ideation more effectively than therapy focused on a mental health issue other than suicidality: that’s logical.
However, at first blush, the results on suicide attempts – a more serious metric than suicidal ideation – are surprising:
They show only a small statistical difference between direct and indirect psychotherapy, with indirect psychotherapy reducing suicide risk at a greater rate than direct psychotherapy.
That didn’t make sense, at first. Then we realized that both types of therapy – whether focused on suicide or something else – address root causes of suicidality. In other words, when a mental health disorder such as depression increases suicide risk, effective psychotherapy that reduces depressive symptoms may also reduce the associated risk of suicide.
The same is true for the other disorders. If the symptoms of disorders such as anxiety or post-traumatic stress disorder contribute to suicide risk and psychotherapy reduces or eliminates those symptoms, then that psychotherapy – considered indirect, with regard to suicide – may also reduce associated suicide risk.
That’s important information, which can help us understand the relationship of suicidality to the mental health disorders and patients we see and treat every day.
We’ll close this article by sharing warning signs and risk factors for suicide that everyone should know about.
Suicide: Warning Signs and Risk Factors
Warning signs are behaviors or statements that reveal a high risk of an imminent suicide attempt. Risk factors are elements in the life of an individual that increase the likelihood they may attempt suicide. We’ll list the warning signs and risk factors for suicide below, starting with the warning signs.
The National Alliance on Mental Illness (NAMI) identifies the following warning signs for suicide.
Suicide Warning Signs
- Escalating drug or alcohol use
- Increased aggression/anger
- Withdrawal from family and friends
- Intense, frequent mood swings
- Escalating risky or impulsive behavior
- Acquiring means to commit suicide
- Giving favorite items or possessions away
- Saying goodbye to family, friends, and loved ones
If someone close to you shows those warning signs, it’s important to do one of two things, and both, if possible:
- Check in to see how they’re doing. Evidence shows that asking direct questions about suicide does not increase suicide risk.
- Help them arrange, or arrange for them, a full psychiatric evaluation administered by a qualified, experienced mental health professional.
It’s also important to understand that engaging in suicidal behavior – ideation, planning, or attempts – meets the criteria for a mental health emergency. The behaviors we list above are associated with a high risk of an imminent suicide attempt and should always be taken seriously.
Now let’s look at suicide risk factors identified by NAMI:
Suicide Risk Factors
- History of suicidality in family
- Alcohol intoxication
- Easy access to guns or other lethal means
- Chronic physical or mental illness
- History of trauma
- History of physical or sexual abuse
- Chronic stress
- Death in family/other significant loss
Let’s be clear. The presence of risk factors and warning signs don’t mean that a person definitely will attempt suicide. What they indicate is that the individual who shows/experiences them may need some form of external support managing their thoughts, emotions, and behavior. Those warning signs tell others something is not right, while risk factors tell others that there are circumstances at play, which, when viewed in light of warning signs, are significant cause for concern.
Therefore, if someone you know shows those warning signs and/or risk factors, we encourage you to take the two steps we suggest above. In addition, please see the bold text at the bottom of this page, and remember:
NEVER IGNORE SUICIDALITY OF ANY KIND.
Resources: Support for Suicidal Thoughts and Behavior
If you or someone you care about is at risk of suicide, please get help immediately:
- If the danger is immediate, call 911 now.
- If the danger is serious but risk of harm is not immediate – meaning about to happen now – call or text the 988 Suicide & Crisis Lifeline at 988.
- The 988 crisis line connects callers trained professionals who can assess your needs and refer you to an appropriate resource in your area.
- The Trevor Project (designed for LGBTQIA+ Youth and Teens)
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- Phone (24/7/365): 1-866-488-7386
- Trevor Project Text (7 days/wk, 6am-am ET, 3am-10pm PT): Text START to 678678
- The Trevor Project Chat: CLICK HERE
Gianna Melendez
Jodie Dahl, CpHT