Suicidal Thoughts

Suicidal thoughts (suicidal ideation) range from passive thoughts of death or wishing to be dead to active planning of suicide. Suicidal thoughts are common in mental illness and warrant evaluation. Free 24-hour Canadian crisis support is available; effective treatment exists.

Overview

If you are having thoughts of suicide right now, free 24-hour Canadian crisis support is immediately available:

9-8-8 — Suicide Crisis Helpline (call or text). Free, 24/7, available across Canada.
1-833-456-4566 — Talk Suicide Canada (call); text 45645, 4 PM–midnight ET.
1-800-668-6868 — Kids Help Phone (under 20).
1-855-242-3310 — Hope for Wellness Helpline (Indigenous-led, 24/7).
911 or local emergency department if you are in immediate danger or unable to keep yourself safe.

Suicidal thoughts (suicidal ideation) are thoughts about death, wishing to be dead, or about ending one’s life. They exist on a continuum from passive ideation (wishing to be dead, hoping not to wake up) to active ideation (thinking about specific methods, planning, intent to act). Suicidal thoughts are clinically significant and warrant evaluation regardless of where on this continuum they fall.

Suicidal thoughts are not in themselves a DSM-5-TR diagnosis. They occur as features of multiple mental-health conditions (most commonly major depressive disorder, bipolar disorder, borderline personality disorder, post-traumatic stress disorder, substance use disorders, eating disorders, and psychotic disorders), and as responses to acute crisis (loss, trauma, financial collapse, public exposure, illness diagnosis). The DSM-5-TR includes Suicidal behaviour Disorder in Section III (“Conditions for Further Study”) for individuals who have made a suicide attempt within 24 months.

Population data: approximately 3-4% of Canadians report suicidal ideation in the past year; approximately 1-2% report serious suicidal ideation; approximately 0.5% report a suicide attempt in the past year. Approximately 4,500 Canadians die by suicide each year. Suicide is a leading cause of death, particularly for ages 15-34 (third leading cause). Suicide rates are substantially elevated in older men, Indigenous youth, LGBTQ+ youth, and military veterans.

Suicidal thoughts often emerge during periods of intense psychological pain (“psychache”; Shneidman) when problems feel inescapable, intolerable, and interminable. Effective treatment substantially reduces suicidal ideation and suicide risk. Most people who experience suicidal thoughts at some point in their lives do not die by suicide; many achieve sustained recovery and meaningful life.

Asking about suicide does not increase risk and frequently saves lives. If you are concerned about someone, ask directly. If you are having thoughts yourself, reaching out to crisis support, a clinician, or a trusted person is one of the most important things you can do.

Signs and symptoms

Thoughts of death or wishing to be dead — Passive ideation: thoughts about death, wishing not to wake up, hoping to die from accident or illness.
Active suicidal ideation — Thinking about ways to die, considering suicide, having ideas about how, when, where.
Suicidal planning — Specific plans about means, time, location; preparing for suicide; gathering means.
Suicidal intent — Sense of intent to act on suicidal thoughts; difference between "I think about suicide" and "I plan to act on it."
Hopelessness — Sense that things will not improve; problems feel inescapable, intolerable, and interminable. One of the strongest single predictors of suicide.
Acute psychological pain — Intense emotional pain that feels intolerable; "psychache" — overwhelming desire to escape from pain.
behavioural changes — Withdrawal from activities and relationships; giving away possessions; saying goodbye; researching methods; sudden calm after distressed period.
Mood and anxiety symptoms — Often coincident depression, anxiety, agitation, mixed features; sleep disturbance; concentration difficulties.
Substance use — Increased substance use as coping; alcohol use elevates impulsivity and lethality risk.
Comorbid mental-health conditions — Mood disorders, substance use disorders, BPD, PTSD, eating disorders, psychotic disorders all elevate risk.

Diagnostic context

Suicidal ideation is not a discrete DSM-5-TR diagnosis. It is a feature of multiple conditions and a clinical phenomenon warranting evaluation. The DSM-5-TR includes:

Suicidal behaviour Disorder (Section III) — research category for individuals who have made a suicide attempt within 24 months. Not for ideation alone.
Suicidal ideation as a symptom criterion in major depressive episode (recurrent thoughts of death, recurrent suicidal ideation without specific plan, suicide attempt, or specific plan for committing suicide).
Suicidal ideation as a feature in many other conditions (bipolar disorder, BPD, PTSD, schizophrenia, eating disorders, substance use disorders).

Comprehensive suicide risk assessment includes:

Ideation: nature, frequency, intensity, duration of suicidal thoughts.
Intent: degree of intent to act on thoughts.
Plan: specific plan, method considered, means access, timeline.
Lethality: lethality of method considered or accessible.
Prior attempts: strongest single predictor of subsequent attempts and completions.
Risk factors: mental illness, recent stressor, social isolation, hopelessness, substance use, family history, demographic factors.
Protective factors: reasons for living, social support, treatment engagement, religious/spiritual beliefs, family responsibilities.
Means access: firearms, lethal medications, other lethal means.

Validated risk assessment instruments include the Columbia Suicide Severity Rating Scale (C-SSRS), Beck Scale for Suicide Ideation (BSSI), and structured clinical interview.

Causes and risk factors

Suicidal ideation arises from interaction of multiple factors:

Mental illness: mood disorders are present in ~50% of suicide deaths; substance use disorders present in ~25-50%; psychotic disorders, BPD, eating disorders, PTSD all substantially elevate risk.

Hopelessness: the cognitive sense that problems are inescapable, intolerable, and interminable is one of the strongest single predictors of suicide.

Acute stressors: recent loss (relationship, job, financial), recent discharge from psychiatric care, legal problems, public humiliation, recent traumatic event.

Means access: firearms in the home substantially elevates suicide death rates; access to lethal medications, other lethal means.

Demographic factors: older men have highest completed-suicide rates in Canada; LGBTQ+ youth have substantially elevated risk; Indigenous youth have very elevated rates in some regions; veterans, healthcare workers, first responders.

Family history: family history of suicide elevates risk independent of mental illness.

Childhood adversity: ACE exposure substantially elevates lifetime suicide risk.

Social factors: social isolation, recent bereavement, exposure to suicide (contagion effect, particularly in adolescents), discrimination, marginalization.

Comorbidity: depression + substance use + impulsivity + means access produces substantial multiplicative risk.

Typical treatments

Effective treatment for suicidal ideation includes:

Crisis intervention: 24/7 crisis lines, mobile crisis teams, emergency department evaluation, brief crisis stabilization, inpatient hospitalization when appropriate.

Safety planning (Stanley & Brown): structured plan addressing recognizing warning signs, internal coping strategies, social contacts for distraction, contacts for crisis support, professional resources, and means restriction. Strong evidence base; core intervention.

Means restriction: reducing access to lethal means (firearms, medications, particularly during periods of elevated risk) is one of the most evidence-supported suicide prevention interventions. Includes firearms safety planning, lockboxes for medications, and other approaches.

Cognitive behavioural Therapy for Suicide Prevention (CBT-SP): structured approach focused on suicide-specific cognitions (hopelessness, perceived burdensomeness, thwarted belongingness), behavioural patterns, and safety planning.

Dialectical behaviour Therapy (DBT): strongest evidence base for chronic suicidality and self-harm, particularly with BPD or chronic emotion dysregulation.

Collaborative Assessment and Management of Suicidality (CAMS): structured framework focused on collaborative assessment and treatment planning.

Mentalization-Based Treatment (MBT): particularly when BPD is part of the picture.

Treatment of underlying mental illness: evidence-based treatment of comorbid depression, BPD, PTSD, substance use, eating disorders, psychotic disorders.

Pharmacotherapy:

Lithium has unique anti-suicide effects in mood disorders (particularly bipolar disorder).
Clozapine has unique anti-suicide effects in schizophrenia.
Ketamine and esketamine have rapid anti-suicide effects in treatment-resistant depression.
SSRIs and other antidepressants treat underlying mood/anxiety; treated depression carries lower suicide risk than untreated.

Hospitalization: appropriate for acute suicide risk with plan, intent, means, recent attempt, or inadequate outpatient resources.

Family involvement: family education, support, means restriction at home, contact during transition periods.

Peer support: survivor-of-suicide-attempt peer support, mental-health peer support.

When to seek help

If you are having thoughts of suicide right now, free 24-hour Canadian crisis support is immediately available — see crisis numbers at the top of this page.

Professional support is indicated when:

You are having thoughts of suicide — passive (wishing to be dead) or active (planning).
You are experiencing intense psychological pain that feels intolerable.
You feel hopeless about your situation improving.
You have a mental-health condition (depression, bipolar disorder, BPD, PTSD, substance use disorder, eating disorder) that elevates risk.
You have made a suicide attempt — recent or in the past — and are continuing to struggle.
You are recently bereaved by suicide.
You are concerned about a friend or family member.

For families and friends concerned about someone: ask directly about suicide (“Are you having thoughts of suicide?”); listen without judgment; do not minimize or argue; help them connect to crisis resources or take them to emergency department; remove or secure lethal means (firearms, medications) when possible; involve other supports; maintain contact in the period after.

Centre for Suicide Prevention (suicideinfo.ca) provides resources for individuals, families, and clinicians.

Frequently asked questions

Is asking someone about suicide harmful?

No. Research consistently shows that asking about suicide does not increase risk and frequently reduces it. Direct asking ("Are you having thoughts of suicide?") allows the person to be honest about their experience and connect to support. Avoiding the topic is more dangerous than asking.

What is the difference between passive and active suicidal ideation?

Passive ideation involves thoughts of death or wishing to be dead without specific intent to act. Active ideation involves thinking about specific means, planning, or intent. Both are clinically significant and warrant evaluation; active ideation with plan and means access carries higher acute risk.

Will I be hospitalized if I tell my therapist about suicidal thoughts?

Not typically. Most suicidal ideation does not require hospitalization. Clinicians use comprehensive risk assessment — considering ideation, intent, plan, means, history, supports — to determine the appropriate level of care. Hospitalization is one option for acute high-risk situations; safety planning, more frequent outpatient contact, family involvement, and means restriction are more common interventions.

Will antidepressants make my suicidal thoughts worse?

There is a small short-term elevation of suicidal ideation in some adolescents and young adults starting SSRIs (FDA black-box warning). However, untreated depression carries substantially higher suicide risk than treated. Careful monitoring during medication initiation addresses this; medication remains an important part of treatment for underlying depression.

Can suicidal thoughts go away?

Yes. Most people who experience suicidal thoughts at some point do not act on them and many achieve sustained recovery. Effective treatment substantially reduces suicidal ideation. Crisis is typically time-limited; safety planning helps people get through acute periods until improvement.

How do I help someone with suicidal thoughts?

Ask directly; listen without judgment; do not minimize or argue; help them connect to crisis resources (988 in Canada); take them to emergency department if necessary; remove or secure lethal means; involve other supports; maintain contact over time. Your willingness to engage often makes a meaningful difference.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
Mann, J. J., et al. (2021). Improving suicide prevention through evidence-based strategies: A systematic review. American Journal of Psychiatry, 178(7), 611–624.
Stanley, B., & Brown, G. K. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and behavioural Practice, 19(2), 256–264.
Centre for Suicide Prevention (Canada). (n.d.). Resources for individuals, families, and clinicians.
Public Health Agency of Canada. (2023). Suicide in Canada: Key statistics.

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ShiftGrit Psychology & Counselling is professionally regulated, certified, and recognized by leading psychology and mental-health organizations across Alberta and Canada. These associations reflect our commitment to ethical practice, clinical standards, and evidence-informed therapy through Identity-Level Therapy and Reconditioning.

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The ShiftGrit Clinical Editorial Team combines the insight of registered psychologists, provisional psychologists, and trained writers to create accessible, evidence-informed therapy resources. All content is clinically reviewed by a Registered Psychologist.