It is the hardest topic to talk about and the one that needs to be discussed the most.

Editor’s Note: This content delves into sensitive topics that some readers might find distressing. If you or someone you know is having suicidal thoughts, call or text 988 to reach the Suicide and Crisis Lifeline, available 24/7. You are not alone. Help is available.

Although it’s a scary topic, it’s important that Suicidal Thoughts and behavior be talked about and taken seriously. While suicidal thoughts and actions are a part of bipolar disorder for some people, they can be treated before individual thoughts turn into tragic actions.

According to the American Foundation for Suicide Prevention (AFSP), an estimated three to 20 percent of persons diagnosed and hospitalized with bipolar disorder die by suicide. Yet, 80 to 90 percent of those who have bipolar disorder can be treated effectively with medication and psychotherapy, the AFSP maintains.

My Story

I know from personal experience that even those of us with chronic bipolar disorder symptoms can learn to live with — and prevent — suicidal thoughts. I’ve had suicidal thoughts and hallucinations for more than 20 years. I still have these thoughts and visions when I get stressed. In fact, while writing this article I took a break and went outside to cut some roses. As I bent over, I saw my eye get poked out by a stick in the ground. I had the thought that I wished I were dead. Instead of getting scared by these thoughts, I cried a bit at how unfair this illness is. I got mad at bipolar disorder and admitted to myself that I’d taken on too much this week and needed a break. I went back and finished the article.

Passive and Active Suicidal Thoughts

You may be wondering how it’s possible to be suicidal for more than 20 years and not try to kill yourself. I have never attempted suicide, even though I have thought about it. The reason is that there are two types of suicidal thoughts: passive and active ones. Mine have been the passive kind, in that I pictured my death and hoped for my death, but never felt the compulsion to end my life. Even those of us with chronic bipolar disorder symptoms can learn to live with — and prevent — suicidal thoughts.

Active thoughts are markedly different from these passive suicidal thoughts, however. My former partner, Ivan, who also has bipolar disorder, was actively suicidal following a three-month hospital stay for psychotic mania. When it happened, I managed to get Ivan to the hospital, where he was put on an antipsychotic and survived. This was the scariest time of my life. Ivan later told me he had methodically planned how he was going to kill himself. Ivan is now doing well and has never had another suicidal episode.

Put another way, people who have passive suicidal thoughts wish for death; people with active suicidal thoughts plan how they are going to die. Naturally, active thoughts are much more serious and require immediate intervention, first and foremost, to ensure safety and then to manage the symptoms that might be contributing to the suicidal thoughts, generally with therapy and medication. Passive thoughts have more of a treatment window, but they must also be treated aggressively, as they may become active thoughts.

Why Suicidal Thoughts are Seductive

My bipolar disorder is often so intense that it rips through my entire body like a tornado. At other times, the bipolar literally makes me catatonic. It’s as though all the life has been sucked out and all that’s left is the shell.

Because of this, suicidal thoughts can be a comfort. They seduce you and talk to you and obsess you to the point that you literally think of nothing else. (If you’re a family member or friend, it may be impossible to imagine this. However, if you can understand that suicide is not about ending life — that it’s about ending pain — it makes more sense that someone in so much pain would want relief.) It’s important to know exactly what you need to do once you become suicidal:

• Tell someone very clearly that you’re suicidal and that you have a plan to kill yourself. This will be very hard, as the illness does not let you think that you need help.
• Go to a hospital emergency room and tell the truth. Forget about pride. Forget about what the thoughts are “saying.” Just fight them and do it. Even short-term care and medication can save your life.
• Check your medications carefully. Some can cause suicidal thoughts.
• Write a list of your typical suicidal thoughts, whether they be active or passive, and memorize this list. When the very first suicidal thought occurs, you will be able to look at your list, reminding yourself that suicidal thoughts mean you need help immediately.
• Look at your lifestyle and determine what triggers could be causing these thoughts.

Suicide Prevention for Family and Friends

According to the National Institute for Mental Health, “If someone is suicidal, he or she must not be left alone. Try to get the person to seek help immediately from his or her doctor or the nearest hospital emergency room, or call 911. It is also important to limit the person’s access to firearms, medications, or other lethal methods for suicide.”

In my book coauthored by John D. Preston, PsyD, Loving Someone with Bipolar Disorder: Understanding and Helping Your Partner, we talk about how to prevent what I call the “suicidal bipolar conversation.” The idea is to help the suicidal person, rather than try to talk him or her out of the pain. Below is an example of the typical bipolar conversation that surrounds suicidal thoughts (which could be either active or passive in nature).

Person with bipolar disorder: I can’t live like this anymore. The walls are closing in on me. I don’t love you anymore and see no point to this worthless life. I’ve never done anything right. Nothing tastes good anymore. I’ve had enough. I’m not sure why I’m even on this hopeless, pointless planet.

Typical reaction: What? What are you talking about? So many people love you. Your life isn’t pointless. You mean so much to me. I love you! Please don’t do this. Don’t scare me like this! Please look at me. This isn’t like you. What happened? What did I do? Look at me! I love you!

Recommended response to suicidal talk: I hear what you’re saying and I know you’re in terrible pain. You have bipolar disorder and these thoughts are taking over your brain. We have to get you help. I’m going to call your doctor right now and we will get help for you. These thoughts are scary and you want to act on them, but you’re feeling this way because you’re sick.

Reacting with dismissal of the severity of the situation, or letting things go because you don’t know what to say or how to help, can have tragic consequences. Instead, the minute you think someone is suicidal, you need to take action and ask the individual some tough questions:

• Are you passively suicidal? (Are you thinking about killing yourself?)
• Are you actively suicidal? (Are you ready to act to kill yourself?)
• Do you have a plan to kill yourself? Can you tell me about it?
• When was your last suicidal thought?

When you are sure your loved one is actively suicidal, call a mental health advocate for an assessment. If this isn’t possible, call the police. If the law-enforcement or health-care professional involved feels there is a risk, they can take your loved one to the hospital for an evaluation. Be prepared to be frustrated and scared by this process, as the suicidal person may try to convince the professional that he or she is fine.

If you suspect that your loved one is suicidal, you can help him or her through the episode, then create a plan to help this person prevent suicidal thoughts in the future:

• Make a list of the signs you see when your loved one is suicidal. What does he or she say and do at the beginning? Use this list to help you spot the signs of suicidal behavior.
• Know your loved one’s doctor and talk with your loved one before things get out of hand. Talk now with your local mental health advocacy group as well. Obtain any information you need to prevent a crisis in the future. Write down the steps you will need to take.
• Deal with your own fear after you get help for your loved one. You may then crash because the adrenaline will leave your body. This is normal.

“It is essential that family members and friends are prepared before a crisis begins,” says John Holmes, executive director of NAMI (National Alliance on Mental Illness) in Portland, Oregon. “Family members are often not even considered as traditional [caregivers] and people end up crashing again because there is a lack of support.” This is precisely why family members and friends need to have a plan in place before a loved one becomes suicidal.

You are often the number-one advocate for your loved one. Get prepared now so that you will not have to face a crisis in the future.

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People Who Have Bipolar Disorder Can Help Themselves

Suicidal thoughts are a sign that you need immediate help from a professional, especially if you’re starting to think of a plan on how to die. Your sick brain wants you to think suicide is an option, but it is not true. Every single person who makes it through a suicidal episode will tell you the same thing — he or she was not thinking rationally when suicidal. They’re so glad instead they didn’t kill themselves. Work together with family members, friends, and health-care professionals to create a plan you can use at the first signs of suicidal thoughts.

I’ve learned to control and live with my suicidal thoughts, even when they’re scary and graphic — and I stay alive. I know you can do the same.

Passive Suicidal Thoughts

I wish I could die/get hit by a bus/get in a car crash.
I want to get cancer and die/I wish someone would murder me.
I think that things would be easier for everyone if I were dead.

Active Suicidal Thoughts

I’m going to kill myself.
I have a plan for how I would kill myself

For help, call 1-800-273-TALK or 1-800-SUICIDE
Or consult these Web sites for expert advice:

www.healthyplace.com/Communities/Depression/nimh/bipolar_suicide.asp

www.nimh.nih.gov/HealthInformation/GettingHelp.cfm

www.suicideinfo.ca/

www.cdc.gov/ncipc/

www.afsp.com/

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UPDATED: Originally printed as “Straight talk about suicide”, Winter 2006

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