What is Suicidal Behavior Disorder?

Suicidal Behaviour Disorder (SBD) refers to a pattern of self-directed behaviors with intent to die, including suicide attempts, preparatory acts, and serious ideation with intent or plan. DSM-5 included SBD as a condition for further study — regardless of diagnostic label, any suicidal behaviour requires urgent clinical attention and a safety-first response.

Key definitions

• Suicidal ideation: Thoughts about wanting to die, ranging from passive wishes to active planning.
• Suicide attempt: A self-injurious act with at least some intent to die.
• Preparatory acts: Behaviours taken to prepare for a suicide attempt (e.g., obtaining means, writing notes).
• Self-harm (non-suicidal): Self-injury without intent to die — needs assessment to determine intent.

Risk factors

• History of previous suicide attempts (strongest single predictor).
• Mood disorders (major depression, bipolar disorder), psychosis, substance use disorders.
• Personality disorders (e.g., borderline), impulsivity, aggression.
• Chronic pain, terminal illness, severe disability.
• Recent stressors: relationship breakdown, bereavement, loss of job, legal issues.
• Access to lethal means (firearms, medications, high places).
• Family history of suicide; social isolation; stigma; history of trauma or abuse.

Protective factors

• Strong social support and connectedness.
• Access to effective mental health care and crisis services.
• Problem-solving skills and reasons for living (responsibilities, values).
• Restricted access to lethal means and safety planning.
• Stable housing and access to community resources.

Warning signs

• Talking about wanting to die or to be dead.
• Expressing hopelessness, feeling like a burden.
• Researching methods or obtaining means.
• Sudden calmness after a period of depression (possible decision to act).
• Giving away prized possessions, writing goodbye notes.
• Increased substance use, agitation, reckless behaviour.

Assessment — immediate priorities

When suicidal risk is suspected, perform a rapid but thorough assessment focusing on current intent, plan, means, protective factors and imminence. Use validated tools as adjuncts.

1. Ask directly: “Are you thinking about ending your life?” (Direct questioning does not increase risk and increases safety.)
2. Clarify intent & plan: Ask about timing, method, preparation, and likelihood of acting.
3. Assess severity: Frequency, controllability of thoughts, past attempts, substance use that reduces inhibition.
4. Check means: Does the person have access to medications, weapons, or other lethal means? Can access be removed or secured?
5. Identify supports & reasons for living: Who can be mobilised, what stops them from acting?
6. Decide level of care: outpatient with safety plan vs urgent psychiatric referral vs emergency department / inpatient care.

Screening tools (commonly used)

• Columbia-Suicide Severity Rating Scale (C-SSRS)
• Beck Scale for Suicide Ideation (BSS)
• Patient Health Questionnaire (PHQ-9) — item 9 screens for ideation

Safety planning — a brief template

1. Warning signs (what I notice early).
2. Internal coping strategies (things I can do without contacting anyone).
3. People & places for distraction and support.
4. People to contact for help and how to reach them.
5. Professional contacts & emergency numbers.
6. Steps to make the environment safer (remove means).

Evidence-based treatments

• Brief interventions & Safety planning: Demonstrated to reduce imminent risk and increase help-seeking.
• Psychotherapies:
  • Cognitive Behavioural Therapy for Suicide Prevention (CBT-SP): targets suicidal thinking, problem-solving & safety planning.
  • Dialectical Behavior Therapy (DBT): effective for reducing suicide attempts and self-harm, especially in borderline personality disorder.
  • Collaborative Assessment and Management of Suicidality (CAMS): framework for assessing and treating suicidal risk collaboratively.
• Pharmacotherapy: Treat underlying psychiatric conditions (antidepressants for depression, mood stabilisers for bipolar disorder, antipsychotics where indicated). Lithium has evidence for reducing suicide risk in mood disorders; clozapine reduces suicide risk in schizophrenia.
• Follow-up & post-attempt care: Rapid follow-up after ED visits and post-attempt outreach reduce repeat attempts.

Management pathway — brief

1. Immediate assessment & safety measures (remove means, safety plan).
2. Decide level of care: outpatient with close follow-up vs urgent referral/admission.
3. Begin evidence-based psychotherapy and treat comorbid conditions.
4. Engage family/supports (with consent), coordinate care and document plan.
5. Regularly review risk, update safety plan and crisis contacts.

Working with families and carers

• Provide clear psychoeducation about risk signs and how to respond.
• Encourage supportive, non-judgemental contact — avoid shaming or minimising feelings.
• Discuss means restriction and safe storage strategies.
• Coordinate care, involve family in safety planning with the person’s consent where possible.

Legal & ethical considerations

• Balance confidentiality with duty to protect — when someone is at imminent risk, clinicians may need to inform or involve others to ensure safety per local laws.
• Document assessments, decision-making, safety plans and communications thoroughly.
• Use culturally sensitive approaches and respect the person’s values while prioritising safety.

Prevention & public health approaches

• Gatekeeper training for teachers, primary care staff and community leaders.
• Public awareness campaigns to reduce stigma and promote help-seeking.
• Means restriction policies (medication packaging, firearm safety, bridge barriers).
• Improved access to mental health care and crisis services.

Resources & crisis contacts

If you or someone is in immediate danger—call local emergency services (e.g., 112 in India). For non-immediate but urgent help, contact national or local suicide prevention helplines and mental health services. Keep a list of local crisis teams, emergency departments and outpatient psychiatry contacts accessible.

Key takeaways

• Any suicidal behaviour requires immediate, compassionate, safety-focused response.
• Direct assessment of intent, plan and means is essential; use tools like C-SSRS as needed.
• Evidence-based interventions (safety planning, CBT-SP, DBT, appropriate pharmacotherapy) reduce risk.
• Engage supports, limit access to means, and ensure timely follow-up and continuity of care.