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Get the Message, Save a Life

September 19th, 2011

This article was funded though a generous grant from the Charles E. Kubly Foundation.

How many messages do you receive each day? Whether it’s a handful or a hundred, would you recognize a message that means life or death? Would you know how to respond? This was the dilemma that Marcus faced.* How would he react to a text that read, “I am sorry, but this is the only way.” How would you respond to such a text? Marcus and his friends jumped into action. They found the girl who sent the text, convinced her to go with them and took her to safety. (See Ref 6) Marcus saved a life that night, not because he received a text, but because he got the message and knew what to do. You can get the message too. You can save a life!

BE INFORMED   

In the United States, thousands of teenage lives are lost to suicide every year. (See Ref 1) The harsh reality is that every minute of every day someone tries to take his or her own life. (See Ref 2) When a suicide is completed, the results are devastating. People lose friends and coworkers. Families lose mothers, fathers, brothers, sisters and children. The world will never fully know the talent, creativity and genius that are swallowed up by suicide. Many feel uncomfortable or ashamed to talk about suicide, but this makes it harder for people to get help and harder for you to help others. (See Ref 1)

Depression, bipolar disorder and other mental health conditions increase the risk of suicide. Other contributing risk factors include alcohol abuse, drug abuse, family violence, family history of mental health disorders and family history of drug abuse. Those who have attempted suicide in the past are also more likely to attempt suicide again. A chemical imbalance may be partly to blame. Research has found lower levels of serotonin in the brains of people who attempt suicide. (See Ref 3 & Ref 7 pg 10 par 1 and page 18 box)

BE AWARE     

People who are at risk for suicide generally give warning signs. You may notice that a friend doesn’t want to hang out anymore. He may quit doing the things he once loved. He may start looking different, like he doesn’t care about his appearance anymore. He may also become irritable or angry. He may seem exhausted and start falling behind in school. He may do very risky things to tempt death, like driving extremely fast or in the wrong lane. He may become involved in drinking or drug abuse. He may complain about headaches, stomachaches and not feeling well in general. He may seem hopeless or depressed. He may not want to hear anything good about himself. All of these things are warning signs.     

If a friend already has a suicide plan, he may give you important personal items. He may start saying things like “It doesn’t matter,” “There’s no way out” or “Everyone would be better off without me.” He may become cheerful for a time after a period of depression. You may be confused by this bizarre behavior.  He may even say he wants to die.  (entire subheading See Ref 1 & 4)

BE PROACTIVE     

If you recognize the warning signs of suicide in a friend or relative, don’t wait until that person makes a suicide threat or attempt. Let your friend know that it’s okay to get treatment for depression and other mental health conditions and that you will be supportive. Such treatment appears to be the best way to prevent suicide. (Ref 2)       

Be careful not to minimize or belittle the feelings of your friend. Saying things like “It’s not so bad” or “Toughen up!” does not help. Instead, listen to your friend and, when you do speak, use calm and comforting words, such as “I’m sorry that you hurt” and “I’m here for you.”      

Don’t be surprised if your friend responds with extreme emotions, such as tears or anger. This is part of his delicate emotional state and is to be expected. It’s okay to ask your friend if he is having suicidal thoughts. Talking about suicidal thoughts won’t increase the risk of suicide but could actually save your friend’s life. (See Ref 1)   

If your friend is already in the middle of a crisis and making suicidal comments, take him seriously and act immediately. Don’t ever agree to keep thoughts of suicide a secret. Here are some things you can do: (list Ref 3 & 5)

  • Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or call 911.
  • Call a trusted adult, such as parent; close family member, coach or teacher.
  • Do not leave the person alone while waiting for help.
  • Remove medications and alcohol along with dangerous objects, including sharp items and weapons. 
  • Take the person to an emergency room.

GET THE MESSAGE   

Of the hundreds of messages you receive, this one may be the most important to you and someone you love. If you are informed, aware and proactive, you can save a life! That one act will touch the lives of countless others—and change your life forever.

*Names have been changed.

Tough Questions about Suicide: Real Answers

Fast Fact
In 2009, more Marines were lost to suicide than combat in Afghanistan. (See Ref 23)

Is it true that boys die by suicide more frequently than girls?

Be Informed: Boys between the ages of 15 to 24 have a much higher rate of death by suicide than girls do—five to six times higher. (Ref 27) But that doesn’t mean that girls aren’t at risk for suicide. Girls are actually more likely to report making a suicide attempt than boys. (Ref 28)

Be Aware: Should you conclude, then, that a girl who threatens suicide won’t follow through with that threat? NO! A closer look at the statistics tells us that boys may be more likely to use aggressive means to end their life. This aggressive approach makes survival less likely. Your response to a suicide threat should be urgent regardless of whether your friend is a girl or a boy.

Be Proactive: A friend who is depressed—whether male or female—should NOT have access to any dangerous firearms. While you may not have control over such access, a friend or family member may. Alerting them to the possible danger may help save a life. 

Are teens and young kids really at risk for suicide?

Be Informed:  Yes! In children between the ages of 5 to 14, suicide is the sixth leading cause of death according to the American Academy of Child & Adolescent Psychiatry. They also report that suicide is the third leading cause of death in teens and young adults between the ages of 15 and 24. (Ref 1) For every completed suicide in this teenage bracket, there are another 100 to 200 teens who attempt suicide. (Ref 7 page 4)

Be Aware: It may be easy to think that young people don’t get depressed. While it is a nice fairy tale to pretend that children are worry free and carefree, the reality can be very different. Young people can suffer from depression and other mental illnesses in the same way as adults. Additionally, especially while going through puberty, they are under a great deal of stress and pressure that can fill their lives with fear and self-doubt. Very young children may not have an adequate vocabulary to express suicidal thoughts. 

Be Proactive: Be interested in the kids and teens in your life. Know what’s going on with them at home and school. Encourage them to talk about any problems or stresses. Share your own experiences so they know they aren’t alone. If a young person talks about painful feelings, don’t discount those feelings simply because of his age. If a young person confides in you, make sure the adults in his life are aware of any suicidal thoughts or comments so that they can seek help. Sharing such information is not a betrayal but a means to help the young person.

Does everyone who attempts suicide suffer from a psychiatric illness?

Be Informed: More than 90% of young people who die by suicide suffer from at least one psychiatric illness, such as depression, bipolar disorder, conduct disorders and substance abuse. (See Ref 2) Other conditions that can cause suicidal thoughts or attempts include chronic or intense pain, brain injury, dementia, or a terminal illness, such as cancer. Other factors include financial loss, divorce and disability. (See Ref 8 page2)

Be Aware: While the vast majority of suicide attempts come from those who suffer from a psychiatric illness, this illness may not be recognized or diagnosed. According to the Substance Abuse and Mental Health Services Administration’s 2006 National Survey on Drug Use and Health, fewer than half of the people with serious psychological distress received treatment for a mental health problem. (See Ref 7 page 9) Someone who is experiencing suicidal thoughts may have suffered for years without seeking help. Don’t be fooled into thinking that since a person isn’t diagnosed, he or she isn’t at risk. 

Be Proactive: Pay attention to the warning signs and act, regardless of your friend’s diagnosis or lack of one. Be especially on the alert if she is experiencing several risk factors at one time. Encourage a friend with untreated symptoms to seek the help she needs prior to a crisis.

In the Spotlight
Two middle school students became concerned when a friend started expressing suicidal thoughts on the phone. The two knew that the problem was too big for them to handle on their own so they sought the help of their school counselor. Even though their friend was attending a different middle school, the counselor contacted a fellow counselor at the other school who was able to intervene. (See Ref 24)

Are drugs and alcohol to blame for suicide attempts?

Be Informed: Alcohol abuse and drug abuse are among the most frequent risk factors for suicide, second only to depression and mood disorders. (See Ref 7 page 10 par 1) Active alcohol use or abuse has been established as a strong factor in suicide attempts. Alcohol lowers a person’s normal inhibitions and may allow him to act upon thoughts that may have otherwise been suppressed. While the underlying thoughts are primarily to blame, the role of alcohol is significant. (See Ref 7 page 10 par 7) Additionally, alcohol can promote depression and hopelessness. It impairs thinking and judgment and increases aggressiveness. (See Ref 7 page 11 par1)

Be Aware: When a friend has a psychiatric illness and substance use disorder together, his risk for suicide increases. In 2006, there were 5.6 million American adults suffering from both a substance use disorder and serious psychological distress. (See Ref 7 page 11 & 12) The relationship between drug/alcohol abuse and psychiatric illness is complicated. Untreated illness may lead to self-medication.

Be Proactive: Don’t enable a friend’s behavior by partying together or encouraging alcohol consumption if you know she is abusing alcohol or drugs. Straight talk from a friend may not be what she wants to hear but may be what she needs. Encourage your friend to seek help for a substance use disorder. Remember, you are not a trained professional and your encouragement, while beneficial, can’t replace treatment. She needs specialized treatment to stabilize and stay sober. There are many treatment programs and support programs available to help your friend. 

How do religion and culture affect suicide attempts?

Be Informed: Suicide has been around for centuries. Both culture and religion affect how people view suicide. Some cultures view it as honorable or acceptable while others view it as a dishonor or sin. Suicide has even been romanticized in literature, as in Shakespeare’s famous end to the star-crossed lovers in “Romeo and Juliet.”

Fast Fact
It's estimated that in the United States a suicide attempt is made about once every 40 seconds.
(See Ref 2)

Be Aware: Look at a friend’s actions and words in the context of his religion and culture. For instance, a person whose religious belief condemns suicide may be hesitant to reveal suicidal thoughts and tendencies, feeling that these are sinful and make him wicked. A friend whose cultural background is more accepting of suicide may consider it a realistic option to solve problems.

Be Proactive: Be sensitive to your friend’s cultural and religious beliefs. At the same time, don’t glorify or demonize suicidal thoughts. Help your friend by referring to suicidal thoughts as a health issue that should be addressed promptly. 

Does being bullied cause suicide?

Be Informed: Bullying is a common problem both in school and even later in life. The majority of people who are bullied never become suicidal. However, bullying can worsen feelings of anxiety, despair, isolation and depression. These feelings may, in turn, add to suicidal thoughts. (See Ref 9 box on page 1) Both bullies and victims of bullying experience increased health complaints, according to the American Academy of Pediatrics. (See Ref 10) This shows that even bullies may be experiencing the types of feelings that could create both anxiety and depression. 

Be Aware: Watch for signs of bullying. Bullying takes on many forms. It can be verbal abuse such as name calling, it can be physical abuse including hitting or pushing, and it can be social abuse like spreading false rumors and creating isolation. Be aware that bullying doesn’t just happen at school but may also be happening through social networks (Facebook, Twitter, online chat, etc), email and texts. 

Be Proactive: If you know that your friend is either bullying or being bullied, speak up! Don’t stand by in silence. Encourage your friend to talk to her school counselor or administration to resolve the issue. If she is afraid to do so, offer to go with her to show your support. If she still refuses, talk to a parent, teacher or other trusted adult to see how best to handle the situation. 

In the Spotlight
According to the experience of Hulk Hogan, sometimes just expressing concern and itnerest in a fellow human can be the difference between life and death. Hulk Hogan revealed that in a moment of deep despair he nearly took his own life. Who was his hero? He credits his co-star on "Gladiators," Laila Ali, for saving him with an important phone call expressing concern over his depression and his future. (See Ref 26)

Are young people who are lesbian, gay, bisexual or transgender at greater risk of suicide?

Be Informed: Anyone can suffer from the effects of depression and other psychiatric conditions, including people who are lesbian, gay, bisexual or transgender (LGBT). While most LGBT people do not attempt suicide, surveys in the United States show that this population is 2 to 6 times more likely to make a suicide attempt than the general population. (See Ref 9)  It is not known exactly how many people in the LGBT community die as a result of suicide but there is clearly an increased risk of suicide attempts. 

Be Aware: More than 60% of LGBT youth feel unsafe at school. Nearly 85% are verbally harassed, 40% are physically harassed and over half experience cyber-bullying. (Ref 11 page 18) Along with depression, other risk factors that contribute to suicide attempts in LGBT people are discrimination, hostility, stigma, family rejection and bullying. Most people recognize that bullying is wrong, yet there are some who rationalize that bullying youth who self-identify as lesbian, gay, bisexual or transgender is somehow okay. Others who do not self-identify as such can still be targeted for perceived LGBT traits. 

Be Proactive: Reject all forms of bullying and harassment, including those aimed at LGBT youth. You do not have to share the same ideas, feelings or beliefs of another to treat that person with dignity and respect. Avoid terminology and jokes that target the LGBT community. By doing your part, you will reduce the amount of discrimination against LGBT youth and help protect them against the risk factors for suicide. If you know a youth who identifies as LGBT, watch for signs of bullying and harassment. If your friend has a change in behavior, talk to him about it. Ask if he is being bullied. Don’t be afraid to get a school counselor or trusted adult involved. If you know that a LGBT youth is feeling suicidal, you may be the only one who knows and who can make a difference. Tell someone and encourage your friend to call the Trevor Lifeline at 1-866-4-U-TREVOR or visit http://www.thetrevorproject.org/

If my friend is cutting, does that mean she is suicidal?

Be Informed: Cutting is one form of self-injury and is used by some as an unhealthy coping skill to handle stressful life situations. It’s hard for an outsider to know the intent of someone who self-injures. The American Foundation for Suicide Prevention notes that many such individuals do not have suicidal intent. (See Ref 12 page 11) For some, however, self-injury can be a prelude to a suicide attempt. (See Ref 12 page 11) (Also See Ref 19)

Be Aware: Cutting is not the only means to self-injure. Self-injury can include burning, scratching, hair pulling, piercing, head banging and hitting. If you notice frequent cuts, burns, bruises and scratches on your friend, be aware of the possibility of self-injury. Therapy may help a person who self-injures to find better coping skills. (See Ref 13)

Be Proactive: If your friend is cutting or using some other means of self-injury, he or she needs help to deal with this. Urge your friend to talk to a counselor, parent, teacher, therapist or other trusted adult. 

What if I promised my friend to keep his thoughts of suicide a secret?

Be Informed:  If your friend is having suicidal thoughts, he may want to keep these thoughts a secret for many reasons. He may feel embarrassed by these thoughts or at the idea of needing help. He may not want others to worry about him or to think he is ‘crazy.’

Be Aware: In a friendship, sharing secrets can sometimes draw friends closer together; but not all secrets should be kept. While it may feel like you are protecting your friend, there is no help in secrecy. Help comes through support. 

Be Proactive: Don’t promise to keep suicidal thoughts a secret. If you already made that promise, talk frankly with your friend. You may be able to encourage him to get the help he needs. If he doesn’t respond, you have to do the hardest thing in the world to help your friend—break your promise. Your friend’s life is worth more than his personal privacy or your promise. It is true that you could lose your friend if the promise is broken but if it isn’t broken your friend could lose his life.

How may college affect suicide attempts?

Fast Fact
Suicide is the second leading cause of death in college students.
 (See Ref 2)

Be Informed:  The college years are stressful and a common time for the onset of a psychiatric illness. According to the 2006 National College Health Assessment, 94% of college students feel overwhelmed by everything they have to do. Nearly half of that number feels depressed to the point of finding it difficult to function. 18% suffered from a depressive disorder. College age students (18 to 25) are at greater risk of having suicidal thoughts than adults aged 26 to 49. (Ref 14 page 1)

Be Aware: If your friend is in college, be aware of the extra pressures. Your friend may be trying to study full-time, hold a job and be on her own for the first time. Extra social pressure to party can limit the amount of sleep that your friend is getting. These pressures can be especially strong during final exams.

Be Proactive: Make your friend aware that help is available. College campuses have counselors available to help students deal with these stressors. If your friend is overwhelmed, encourage her to talk to a college counselor. Many college campuses provide special programs and support networks to students who are dealing with depression and other health issues. Refer your college friend to Active Minds at www.activeminds.org.

How can I prevent suicidal thoughts in myself or someone I love? 

Be Informed: Thoughts are funny things. You can’t touch them but they can make you feel. You can’t measure them but they can move you to action. Other people can’t read them but sometimes they are difficult to hide. They can make you smile or haunt you. Even if you conquer your actions, conquering your thoughts is incredibly difficult. 

Be Aware: According to a study published in “Sleep” magazine, sleep deprivation can be one contributing factor to increased suicidal thoughts and depression in teenagers.  The study showed that teenagers who reported having suicidal thoughts were more likely to go to bed later and get less sleep than their peers.  (Ref 15) Difficulty sleeping can also be a sign of depression. This demonstrates the overall need to pay attention to your ‘mental health hygiene’ in order to prevent suicidal thoughts.

Be Proactive: Mental health hygiene includes getting the right nutrition, getting enough sleep (a little more than 9 hours for teens), exercising regularly and dealing with any underlying mental health issues, such as depression and anxiety.  The best way to prevent suicidal thoughts in yourself or someone you love is to take care of your health and encourage them to do the same. Never be afraid to get treatment when needed so that even if you do become depressed, it doesn’t progress to the point of suicidal thoughts.

In the Spotlight
Most people don't get a medal when they save someone from suicide, but twenty-one year old Jonathan Burson did. When Jonathan noticed a fellow Marine sitting alone crying, he took the initiative to talk to him. Jonathan spent hours talking with the young man, and, on the following day, the young man revealed his thoughts of suicide. Jonathan immediately intervened by calling his superiors for assistance, and the young Marine received the help he needed. (See Ref 23)

What if someone is joking about suicide?

Be Informed: Stigma is one of the biggest obstacles to people receiving treatment for mental health issues including depression. What may seem to be a harmless joke to one person could add to the stigma surrounding treatment. Less than half of the people in America think of depression as a health problem and more than 2 out of 5 still believe it is a sign of personal weakness. (See Ref 2 page 3) 

Be Aware: Some people use humorous statements about suicide to hint at a real underlying feeling that they are afraid to communicate. A person joking about suicide may not know any other way to express these scary feelings.

Be Proactive: Don’t contribute to stigma or belittle thoughts of suicide even in a joking manner. If conversation with your friends turns to joking about suicide or other mental health matters, don’t contribute to that. Pay attention to how others react as this may tell you a lot about their own feelings. Remember that a brief comment from you can diffuse the situation and move the conversation in a new direction. If a friend repeatedly jokes about suicide, look for other signs of depression and use a private moment to ask if he has ever seriously thought about suicide.

How do I help a friend who has already made a suicide attempt?

Be Informed: If your friend has attempted suicide, he is likely to experience many different emotions ranging from guilt, shame and anger to relief or even thankfulness. There isn’t one right way for a person to deal with all these emotions. Those who have attempted suicide are 38 to 40 times more likely to attempt suicide again. (See Ref 17)

Be Aware: Just because a suicide attempt did not lead to death does not mean that it won’t in the future. Not all people who attempt suicide seek help or tell others around them. Feelings of depression and isolation can be very strong after a suicide attempt.

Fast Fact
Throughout the world, suicide takes more lives than accidents, homicides, and war combined.
(See Ref 2)

Be Proactive: Show your concern by visiting and listening to your friend. Be supportive. Encourage treatment and offer practical assistance. Don’t judge or criticize. (Ref 16) Don’t discourage your friend from talking about it and don’t push her to talk about it. Just be there for her. Also, pay attention to your own mental health, as the suicide attempt of a friend can put a huge emotional strain on you. Don’t hesitate to see a counselor, if needed, to work through your own feelings.

Does treatment really help? 

Be Informed: Depression and other psychiatric disorders are very treatable. Treatment includes medication, therapy or a combination of both. (Ref 2 page 3) The Journal of the American Medical Association reported that a special kind of therapy called Cognitive Therapy helped reduce a repeat suicide attempt by 50% compared to those who didn’t receive the therapy. (See Ref 18 – Results heading line 8)

Be Aware: Treatment should be tailored to the individual according to both need and diagnosis. Not every form of treatment is right for every person. A small percentage of young people will have an increase in suicidal thoughts after being prescribed certain medications. Other youth receiving medication treatment experience a great deal of improvement. Most young people with a psychiatric illness do not receive help. Of the ones who do, the vast majority do not receive sufficient help. (See Ref 20)

Be Proactive: Treatment can’t help if it is abandoned. Recognize that depressive thoughts on the part of your friend may lead him to believe that nothing will help. If your friend doesn’t feel that treatment is helping, encourage him to talk frankly with his doctor. It is very common for treatment to be adjusted or changed according to the needs of the patient. Similarly, if your friend is experiencing bothersome side effects, the doctor may be able to minimize these with simple changes. 

How do I deal with losing a friend to suicide?

Be Informed: While your actions may save a life, it’s impossible to save every life. When someone you love dies by suicide, the effects on you can be profound. You are not alone in this experience. Each year, 200,000 people are affected by the loss of a loved one or friend. (See Ref 7 page 6 par 1) Each death ripples out and touches many. In fact, 1 in 4 people know someone who has died by suicide. (See Ref 21) While each story is unique, the underlying pain and loss is a shared experience.

Be Aware: Losing someone you love to suicide may cause a confusing mixture of emotions within you. You may feel tremendous guilt, anger, shame and helplessness. The normal grief you would feel having lost a loved one may be intensified with complex and conflicting feelings. 

Be Proactive: Seek out supportive and caring people. Resist the urge to isolate yourself. Recognize that it can take months or even years to accept the change that has happened in your life. Don’t make any big decisions in your life while grieving. Take care of your own health. (See Ref 22) Seek out a grief counselor to help you during this difficult period. Consider joining an organization such as The Karla Smith Foundation or Survivors of Suicide (www.karlasmithfoundation.org and www.survivorsofsuicide.com).   

What if I have suicidal thoughts myself?

Be Informed: Suicidal thoughts may start by thinking that the world would be better off without you, that you wish you hadn’t been born, and that there is no way out. Over time these thoughts may advance to more direct thoughts of hurting yourself. You may become preoccupied with death or dying.

Be Aware: All types of suicidal thoughts are warning signs. You may deceive yourself into thinking you have things under control if your thoughts aren’t as direct as harming yourself. Many people keep suicidal thoughts a secret because they are embarrassed. If you don’t address suicidal thoughts these can progress to a more active suicide plan. 

Be Proactive: If you are having suicidal thoughts, tell someone! Do not keep these a secret. Seek mental health treatment right away. While you may be tempted to drown your feelings, avoid all use of drugs and alcohol as these may intensify depression and your risk of suicide. Don’t try to deal with these feelings alone. If you are in crisis and feel like you want to hurt yourself, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or call 911. You may become your own hero and survive to help someone else.

Can I really make a difference?

Yes you can! Countless people have been saved from suicide by the kindness, concern and actions of a friend or even a stranger. Many of these have gone on to live full and happy lives, even helping to prevent suicide in others. You are not too young nor too inexperienced to be informed, aware and proactive. Don’t ever underestimate your power to save a life. You might not be able to save the world, but you can make a world of difference in the life of one person. You can get the message—you can save a life!

RESOURCES

Suicide Prevention Lifeline 
1-800-273-TALK (8255) 
http://www.suicidepreventionlifeline.org/

American Foundation for Suicide Prevention
http://www.afsp.org/

Suicide Awareness Voices of Education
http://www.save.org/

Yellow Ribbon Campaign
http://www.yellowribbon.org/

Active Minds
http://www.activeminds.org/

Suicide Prevention Resource Center
http://www.sprc.org/

Five Alive
http://fivealive.us/

International Association for Suicide Prevention
http://www.iasp.info/

I’m Alive
https://www.imalive.org/

No Suicide Action Plan
http://childhoodbipolaronline.com/Documents/PrintableNoSuicideActionPlan.pdf

Captain America: A Little help
http://marvel.com/digitalcomics/view.htm?iid=18821

Reach Out
http://us.reachout.com/

Stop Bullying Now
http://www.stopbullying.gov/index.html

Karla Smith Foundation
http://www.karlasmithfoundation.org/

Survivors of Suicide
http://www.survivorsofsuicide.com/

Collateral Damage
http://leftbehindbysuicide.org/

The Trevor Project
http://www.thetrevorproject.org/

Teen Health – My Friend is Talking about Suicide
http://kidshealth.org/teen/your_mind/friends/talking_about_suicide.html#

Friends of Emmet – Coming Apart Suicide Prevention Video
http://www.youtube.com/watch?v=QxAP8ns6mQg&feature=youtu.be

REFERENCES

Ref 1: American Academy of Child & Adolescent Psychiatry: Facts for Families 
http://aacap.org/page.ww?name=Teen+Suicide&section=Facts+for+Families 

Ref 2: The American Foundation for Suicide Prevention: Facts about Suicide
http://www.afsp.org/files/College_Film//factsheets.pdf 

Ref 3: National Institute of Mental Health: Suicide in the U.S.- Statistics and Prevention  
http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

Ref 4: National Institute of Mental Health: Suicide – A major, preventable, mental health problem
http://www.nimh.nih.gov/health/publications/suicide-a-major-preventable-mental-health-problem-fact-sheet/suicide-a-major-preventable-mental-health-problem.shtml

Ref 5: Recommendations for Reporting on Suicide: Suicide Warning Signs
http://reportingonsuicide.org/warning-signs-of-suicide/

Ref 6: Help Promote Hope: A Matter of Life and Death
http://www.helppromotehope.com/documents/Roggenbaum.pdf

Ref 7: Substance Abuse and Suicide Prevention - Evidence & Implications A White Paper http://www.samhsa.gov/matrix2/508SuicidePreventionPaperFinal.pdf

Ref 8: The Joint Commission Sentinel Event Alert: A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department
http://www.jointcommission.org/assets/1/18/SEA_46.pdf

Ref 9: The American Foundation for Suicide Prevention and co-authors: Talking About Suicide & LGBT Populations http://www.hrc.org/documents/talking-about-suicide-and-lgbt-populations.pdf

Ref 10: Pediatrics: Victimization, Aggression, and Visits to the School Nurse for Somatic Complaints, Illnesses, and Physical Injuries. http://pediatrics.aappublications.org/content/127/5/842.full.pdf

Ref 11: Gay, Lesbian and Straight Education Network: The 2009 National School Climate Survey
http://www.glsen.org/binary-data/GLSEN_ATTACHMENTS/file/000/001/1675-1.pdf

Ref 12: American Foundation for Suicide Prevention: Facilitator’s Guide - The Truth About Suicide http://www.afsp.org/files/College_Film//facilitatorsguide.pdf

Ref 13: Mayo Clinic: Self-Injury/Cutting
http://www.mayoclinic.com/health/self-injury/DS00775/METHOD=print

Ref 14: Substance Abuse and Mental Health Services Administration: Preventing Suicide on College Campuses http://store.samhsa.gov/shin/content//SAM11-192/SAM11-192.pdf

Ref 15: Sleep: Earlier Parental Set Bedtimes as a Protective Factor Against Depression and Suicidal Ideation http://www.journalsleep.org/ViewAbstract.aspx?pid=27679#B2

Ref 16: Center for Suicide Prevention: A Suicide Attempt is Meaningful and Significant
http://www.suicideinfo.ca/csp/assets/alert45.pdf

Ref 17: National Institute of Mental Health: Cognitive Therapy Reduces Repeat Suicide Attempts by 50 Percent
http://www.nimh.nih.gov/science-news/2005/cognitive-therapy-reduces-repeat-suicide-attempts-by-50-percent.shtml

Ref 18: The Journal of the American Medical Association: Cognitive Therapy for the Prevention of Suicide Attempts
http://jama.ama-assn.org/content/294/5/563.long

Ref 19: The American Journal of Psychiatry: Clinical and Psychosocial Predictors of Suicide Attempts and Nonsuicidal Self-Injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT)
http://ajp.psychiatryonline.org/cgi/content/abstract/appi.ajp.2010.10050718v1

Ref 20: National Institute of Mental Health: Majority of Youth with Mental Disorders May Not Be Receiving Sufficient Services http://www.nimh.nih.gov/science-news/2011/majority-of-youth-with-mental-disorders-may-not-be-receiving-sufficient-services.shtml

Ref 21: Crisis Link: Surviving the Suicide of a Loved One
http://www.crisislink.org/programs/hope/survivors.html

Ref 22: Healthy Place: Coping with Loss: Bereavement and Grief Page 2
http://www.healthyplace.com/depression/grief/coping-with-loss-bereavement-and-grief/menu-id-68/page-2/

Ref 23: The San Diego Union Tribune: Suicide the unseen enemy for Marines
http://www.signonsandiego.com/news/2010/may/02/suicide-unseen-enemy-marines/

Ref 24: Youth Suicide Prevention Program: Success Stories
http://www.yspp.org/prevention_works/success_stories.htm#top

Ref 25: SAVE: My Story
http://www.save.org/index.cfm?fuseaction=home.viewPage&page_id=7D7DB683-D929-D955-DE3DFF8DE4084F22

Ref 26: Today: Hulk Hogan: Laila Ali saved me from suicide
http://today.msnbc.msn.com/id/33490121/ns/today-books/t/hulk-hogan-laila-ali-saved-me-suicide/

Ref 27: National Institute of Mental Health: Suicide in the U.S.: Statistics and Prevention
http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

Ref 28: Centers for Disease Control and Prevention: Youth Suicide
http://www.cdc.gov/ncipc/dvp/suicide/youthsuicide.htm