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255Suicide and Life-Threatening Behavior 36(3) June 2006
2006 The American Association of Suicidology
Warning Signs for Suicide: Theory, Research,
and Clinical Applications
M.David Rudd,PhD,ABPP,Alan L.Berman,PhD,ABPP,
Thomas E.Joiner,Jr., PhD,Matthew K.Nock,PhD,Morton M.Silverman,MD,
Michael Mandrusiak,MSCP,Kimberly Van Orden,MS,and Tracy Witte,BS
The current article addresses the issue of warning signs for suicide, attempt-
ing to differentiate the construct from risk factors. In accordance with the charac-
teristic features discussed, a consensus set of warning signs identified by the Amer-
ican Association of Suicidology working group are presented, along with a
discussion of relevant clinical and research applications.
CONCEPTUAL ISSUES: Closer to the field of mental health, the
American Psychological Association teamedDIFFERENTIATING WARNING
SIGNS AND RISK FACTORS up with MTV to produce warning signs for
youth violence (Peterson & Newman, 2000).
The basic rationale behind warning signs is
Warning signs have been widely uti- that improved public education and aware-
lized by the general community as a mecha- ness promotes early detection and interven-
nism to prevent a broad spectrum of health tion, with the net result being improved
problems and related disorders. For example, health outcomes in the targeted domain
standardized warning signs for heart attack, (Gould, Greenberg, Velting, & Shaffer,
stroke, and diabetes are widespread and com- 2003). In cases of suicide risk, the end goal
monly known (Carter, 2004; Lee, 2004). would be lives saved.
The standardization and dissemination
of warning signs for suicide have consider-
able appeal from both public health and clin-
M.David Rudd is with Texas Tech Uni-
versity; Michael Mandrusiak is with Baylor ical perspectives and is an issue that has re-
University; Alan Berman is with the American ceived national attention. The President’s
Association of Suicidology; Thomas Joiner,New Freedom Commission on Mental
Kimberly Van Orden, and Tracy Witte are Health (TPNFCMH, 2003) and the Chil-
with Florida State University; Matthew K.Nock dren’s Mental Health Screening and Preven-
is with Harvard University; and Morton M.Sil-
verman is with the University of Chicago. tion Act (CMHSPA, 2003) both call for in-
American Association of Suicidology creased screening for suicidality. Warning
Working Group members included: M. David signs for suicide are routinely distributed to
Rudd, Lanny Berman, Thomas Joiner, Matthew teachers, mental health professionals, pri-
Nock, Greg Brown, Dana Carr, David Chambers, mary care providers, and adolescents as part
Yeates Conwell, Jan Fawcett, Keith Hawton,
Karen Clapper Morris, James Overholser, Mitch of suicide awareness curricula and programs
Prinstein, David Shaffer, Peter Sheras, and Mor- administered in school districts around the
ton Silverman. nation (e.g. AAS, 2005; Nelson, 1987; Shaf-
Address correspondence to M. David fer, Garland, Gould, Fisher, & Trautman,
Rudd, PhD, ABPP, Texas Tech University, Psy- 1990). The most frequently identified warn-
chology Department, MS 42051, Lubbock, TX
79409-2051; E-mail: david.rudd@ttu.edu ing signs have included thoughts of suicide
256 Warning Signs for Suicide
or self-harm; obsessions with death; writing early intervention programs than it is in clin-
ical settings.about death; sudden changes in personality,
behavior, eating, or sleeping patterns; feel- How do warning signs differ from risk
factors for suicide? How do we define aings of guilt; and decreased academic or work
performance (Hosansky, 2004). Warning signs warning sign for suicide? These two ques-
tions trigger a cascade of relevant questions.for suicide are also commonly listed on the
Internet, although there is little consistency For example, are there different warning
signs for suicide attempts relative to comple-and continuity across sites (e.g., Mandrusiak
et al., 2006). This is likely due to the fact tions? Do some risk factors also serve as
warning signs for suicide? At present,that these lists are not based on a clear set of
empirical guidelines that might better define though, we will focus on the most fundamen-
tal questions; that is, how to distinguish riskthe construct of a warning sign. To some de-
gree warning signs, as currently conceptual- factors from warning signs and how to define
warning signs for suicide. The suicide litera-ized, are both signs (something observed in
another) and symptoms (what the individual ture identifies a wealth of risk factors for sui-
cide, along with numerous conceptual ap-reports to another). It is important to note
that the low base rate of completed suicide in proaches to identifying risk factors, associated
clinical formulation, and intervention orthe general population significantly decreases
our ability to accurately predict its occur- treatment and prevention (e.g. Joiner, in
press; Maris, Berman, & Silverman, 2000;rence (Baldessarini, Finklestein, & Arana,
1988). Thus, any warning sign or set of Rudd, Joiner, & Rajab, 2004). For example,
Hendin, Maltsberger, Lipschitz, Haas, andwarning signs will likely result in a number
of false positives, although it is decidedly Kyle (2001) define suicide risk as the pres-
ence of any factor empirically shown to cor-preferable to err on the side of caution when
dealing with such a devastating outcome. relate with suicidality, including age, sex, psy-
chiatric diagnosis, and past suicide attempts;A number of issues need to be clarified
before the utility of warning signs for suicide they contrast suicide risk with the emergence
of a suicide crisis, which is time-limited (notcan be explored empirically. First, little has
been written about differentiating warning chronic and long-standing) and signals po-
tential imminent risk of a suicide attempt orsigns from risk factors in the suicide litera-
ture (e.g., Rudd, 2003). We suggest that completion regardless of the number or type
of risk factors present.there are differences between the two. Al-
though Goodwin (2003) hinted at some of In contrast to the enormous literature
base identifying risk factors, the concept ofthe distinctive features of “acute suicide risk”
(i.e., within one year), the time frame dis- warning signs has yet to be effectively defined
and differentiated from risk factors. Joinercussed is still of limited practical utility in
clinical contexts where decisions are made, and colleagues (1999) report that the key do-
main in assessment of suicidal risk is previousand instructions provided, emphasizing time
frames of hours to days. Second, if the con- history of suicide attempt in combination
with current suicidal symptoms. Thus, long-ceptual parameters of warning signs can be
identified, expert consensus needs to be standing risk factors (e.g., mental illness or
history of past suicide attempt) are not suffi-reached as to what constitutes an identifiable
set of warning signs for suicide. And, third, cient to assess suicide risk; the current state
of the individual must be taken into account.the effects of distributing warning signs for
suicide is not understood and some are con- It is our position that warning signs should
be specific to the current state of the individ-cerned that exposure to subject matter about
suicide may have negative iatrogenic effects ual and thus are theoretically and practically
distinct from risk factors (see Table 1). Per-(Gould et al., 2005; Shaffer et al., 1990). This
is more of an issue in the public education haps most apparent, warning signs suggest a
proximal rather than distal relationship todomain which emphasizes prevention and
Rudd et al. 257
TABLE 1
Differentiating Warnings Signs and Risk Factors for Suicide
Characteristic Feature Risk Factor Warning Sign
Nature of Relationship to Sui- Distal Proximal
cide
Definitional Specificity Defined constructs (e.g., Poorly defined constructs
DSM-IV diagnosis) (e.g., behaviors such as buy-
ing a weapon)
Empirical Foundation Empirically derived Clinically identified/derived
Population Population dependent (i.e., Individually applied
clinical samples)
Timeframe Implies enduring or longer- Implies imminent risk
term risk
Nature of Occurrence Static nature (e.g., age, sex,
abuse history)
Episodic or transient nature
(i.e., warning sign resolves)
Application Context Can be individually explored Likely useful only within cons-
and applied tellation
Implications for Clinical Prac- Limited implications for inter- Specific intervention de-
tice vention manded
Experiential Character Objective Subjective
Intended Target Group Experts and clinicians Lay public and clinicians
suicidal behaviors. In other words, they suggest Heart Association, 2005), but likely lead to
disproportionately high rates of false posi-near-term risk rather than acute or longer-
term risk, with the time period for near-term tives given the subjective nature of the symp-
tom and the fact that shoulder, arm, and neckrisk being hours to a few days.
As has been discussed elsewhere (Rudd, pain can have multiple etiologies. A broad
range of warning signs for suicide has been2003), there are additional conceptual dis-
tinctions between risk factors and warning identified in school-based suicide prevention
programs, with little consistency across pro-signs (see Table 1). What are the characteris-
tic features of warning signs relative to risk grams and many simply incorporating signs
and symptoms of depression (e.g., Hosansky,factors? We can consider a number of charac-
teristic features including: definitional speci- 2004). In terms of a time frame, warning
signs imply near-term risk, whereas risk fac-ficity, empirical foundation, time frame, na-
ture of occurrence (static versus episodic), tors suggest risk over much longer periods,
ranging from a year to a lifetime (e.g., Ruddapplication context, implications for clinical
practice, experiential character, and intended et al., 2004). For example, one of the most
prominent risk factors for suicide is hopeless-target group. With respect to definitional
specificity, risk factors are for the most part ness (Brown, Beck, Steer, & Grisham, 2000),
with the time period covered in empiricalwell-defined constructs that are empirically
derived and population dependent, including studies ranging anywhere from 1 to 20 years.
In terms of the nature of occurrence, manyboth clinical and nonclinical samples. In the
health literature, warning signs have been risk factors are static and enduring (e.g., life-
time psychiatric diagnosis), whereas warningpoorly defined constructs, often without es-
sential empirical support. For example, shoul- signs are episodic and variable (e.g., thoughts
of suicide, behaviors preparing for suicide),der, arm, and neck pain prior to a heart attack
are considered warning signs (e.g., American although this is not always the case. Similarly,
258 Warning Signs for Suicide
risk factors are often explored and applied in- As is apparent, the definition offered is po-
tentially problematic but captures the intentdividually; for example, the role of hopeless-
ness in suicide. Warning signs per se appear behind the identification of warning signs,
with an emphasis on its proximal nature toto have limited meaning and predictive utility
outside the notion of a targeted “constella- suicide or suicidal behavior.
tion” or collection of other signs, aside from
direct statements or behaviors threatening
suicide. As with the emergence of physical REACHING EXPERT CONSENSUS
illness (e.g., heart attack), it is the constella-
tion of certain signs that raise the bar (i.e., In the late fall of 2003, the AAS con-
vened the working group to explore the issuesignifies the emergence of a possible disor-
der), not any one or two symptoms alone. In of warning signs for suicide, with the goal of
reviewing the applicable empirical researchterms of experiential character, risk factors
have a more objective quality (e.g., history of and reaching a consensus on an identifiable
set of warning signs. Since the goal of thisprevious suicidal behavior), whereas warning
signs are more subjective (e.g., threats, talk- article is to address the issue of warning signs
for suicide, we will not offer an extensive re-ing, or writing about suicide). In light of the
time frame and other conceptual issues men- view of the risk factor literature here (such
reviews are available elsewhere; e.g., Maris ettioned, risk factors have limited implications
for immediate intervention and clinical prac- al., 2000; Rudd et al., 2004) or of the back-
ground discussions leading to the final list oftice. For example, age and sex as suicide risk
factors have limited impact on immediate signs documented in Table 2. The central
problem in applying the risk factor literatureclinical decision making with a patient. The
presence of a risk factor that elevates the to warning signs identified by the expert
working group was the issue of time frame,long-term probabilistic risk for a suicidal cri-
sis, in which warning signs indicate the pres- emphasizing the proximal nature of warning
signs to suicide and suicidal behaviors. De-ence of an active suicidal crisis. Thus, the
presence of warning signs would, by defini- spite an extensive and impressive risk factor
literature, few researchers have identifiedtion, demand specific and immediate inter-
vention. Finally, the primary target group in specific signs related to near-term suicide
risk. For example, Hendin et al. (2001) iden-the risk factor literature is experts in general,
including clinicians, educators, and research- tified three signs that immediately preceded
the suicide of a patient: a precipitating event,ers. For warning signs, the target is the lay
public, with hopes of improving awareness “one or more intense affective states other
than depression,” and one of three recogniz-and opportunities for clinical intervention
and clinicians, with hopes of improving clini- able patterns of behavior (speech or actions
suggesting suicide, deterioration in occupa-cal assessment and treatment planning.
Consistent with the characteristic fea- tional or social functioning, and increased
substance abuse). Similarly, Maltsberger,tures reviewed, the following is one possible
definition for a suicide warning sign: Hendin, Haas, and Lipschitz (2003) identi-
fied the characteristics of precipitating events
A suicide warning sign is the earliest in cases of suicide (e.g., initiated by the pa-
detectable sign that indicates height- tient, external event), finding that a precipi-
ened risk for suicide in the near-term tating event occurred in 25 of 26 suicide
(i.e., within minutes, hours, or days). A completions studied. Chiles, Strosahl, and
warning sign refers to some feature of Cowden (1986) found substance abuse and
the developing outcome of interest communication of intent were factors that
(suicide) rather than to a distinct con- most commonly preceded suicide attempts.
struct (e.g., risk factor) that predicts or
may be casually related to suicide. In one of the largest studies ever done with
Rudd et al. 259
TABLE 2
Consensus Warning Signs for Suicide
Are you or someone you love at risk for suicide? Get the facts and take
action.
Call 9-1-1 or seek immediate help from a mental health provider when you
hear, say or see any one of these behaviors:
•Someone threatening to hurt or kill themselves
•Someone looking for ways to kill themselves: seeking access to pills, weap-
ons, or other means
•Someone talking or writing about death, dying, or suicide
Seek help by contacting a mental health professional or calling 1-800-273-
TALK for a referral should you witness, hear, or see anyone exhibiting any
one or more of these behaviors:
•Hopelessness
•Rage, anger, seeking revenge
•Acting reckless or engaging in risky activities, seemingly without thinking
•Feeling trapped—like there’s no way out
•Increasing alcohol or drug use
•Withdrawing from friends, family, or society
•Anxiety, agitation, unable to sleep, or sleeping all the time
•Dramatic changes in mood
•No reason for living; no sense of purpose in life
relevance to the issue of warning signs, differentiates the need for immediate help by
using a two-tier model. The first tier clearlyBusch, Fawcett, and Jacobs (2003) found that
“severe anxiety and/or extreme agitation” was directs the individual to call 9-1-1 or seek
immediate professional help in response tothe most common factor precipitating inpa-
tient suicides. Aside from these few studies, overt suicide threats, preparatory acts (e.g.,
looking for method), and expressed (i.e., ver-little is available in the literature addressing
very short periods of risk (i.e., hours to days) bal or written) thoughts about death, dying,
or suicide. In contrast, the second tier directsconsistent with the concept of warning signs.
Accordingly, the working group was highly the individual to seek help, without specify-
ing immediate assistance, when someonesensitive to the need for an empirical founda-
tion to public education and awareness cam- manifests one of a range of behaviors, all of
which are also recognized risk factors for sui-paigns.
After considerable discussion, the work- cide. As should be clear, the working group
had a simple goal of directing individuals toing group reached consensus on two points:
First, that warning signs need to be presented take action under the conditions noted in Ta-
ble 2, wholly consistent with the imminentin hierarchical fashion (see Table 2), recog-
nizing the importance of the overt expression risk nature of warning signs. Certainly this
two-tier system differentiates warning signsof heightened suicidality; and second, that
any public campaign about suicide warning more clearly associated with near-term risk
from those associated with acute and chronicsigns needs to provide clear and specific di-
rections about what to do if someone mani- risk (i.e., those warning signs that also serve
as risk factors; ultimately, though, research isfests signs of suicidality. The working group
260 Warning Signs for Suicide
needed to answer questions about what truly 2004). Perhaps the primary concern is devel-
oping effective dissemination tools or presen-qualifies as a suicide warning sign.
tation packages that lead to behavioral changes;
that is, prompting individuals to seek help
when needed. A potential model for the dis-A RESEARCH AGENDA
semination of suicide warning signs is Opera-
tion Heartbeat, a community-based informa-The American Association of Suicidol-
ogy (AAS) working group had little difficulty tion dissemination initiative coordinated by
the American Heart Association (1998). Thereaching consensus on the need for addi-
tional research on warning signs for suicide. goal of Operation Heartbeat is to raise public
awareness of both warning signs for heart at-There are three identifiable relevant do-
mains: identification, dissemination, and im- tacks and appropriate emergency responses.
The final domain mentioned by thepact. As mentioned above, differentiating
warning signs from risk factors is an area of working group addresses the impact of warn-
ing signs programs. Concern persists that ex-considerable need given that a concise, clear
list of indicators of imminent danger will en- posure to suicide-related content will have
iatrogenic effects (e.g., Gould et al., 2005).able the general public to appropriately re-
spond as soon as the potential for suicidal be- Indeed, an important component of a public
health campaign should involve factual infor-havior is recognized. As Table 1 indicates,
many of the currently identified warning mation about suicide will not encourage indi-
viduals to consider attempting in combina-signs are also commonly accepted risk fac-
tors, with ample support in the empirical lit- tion with the list of warning signs. The
design and implementation of studies in thiserature. What is needed is research that ex-
plores variables associated with suicide risk area are simple enough and several are al-
ready under way. Van Orden, Joiner, Hollar,over clinically relevant time frames of hours
to days are presented in Table 2. Clinicians and Rudd (2006) used an experimental de-
sign with two conditions (experimental groupmake decisions about suicidal patients with
short time periods in mind, asking questions and control group) to assess possible effects
of the warning signs discussed here. The con-such as: Will this patient be safe for the next
several hours? Will he or she be safe for the trol group read a list of warning signs about
diabetes then a list of warning signs aboutnext several days? Similarly, research is
needed that recognizes that suicidal ideation heart attacks, whereas the experimental group
read the same list of warning signs for diabe-and behaviors are not constant; rather, they
fluctuate (sometimes dramatically) in speci- tes, then the key list of warning signs for sui-
cide. Levels of confidence in the ability toficity and intent over periods of hours and
days. This is in stark contrast to warning recognize warning signs for suicide as well as
questions addressing possible stigmatizing ef-signs for other disorders such as skin cancer
or heart disease, where the warning sign con- fects of the warning signs were administered
to assess both preliminary indications of thestellations do not shift or fluctuate as dramat-
ically as those for suicide. What is clearly effectiveness of disseminating the warning
signs as well as indications of possible iatro-needed is research targeting suicide risk over
clinically meaningful time periods. The net genic effects of disseminating the warning
signs (e.g., stigmatization). If differences areresult will be a more concise identification of
warning signs for suicide. found between the control group and experi-
mental group on ability to recognize suicideThe second domain mentioned ad-
dresses the question of how best to package warning signs, the study design will rule out
certain explanations, such as the effect ofand disseminate warning signs for suicide.
This is a question similar to that already reading warning signs (i.e., all groups read
two sets). Mandrusiak and colleagues (2006)asked by those conducting suicide prevention
programs in the schools (e.g., Hosansky, conducted an investigation of the role of the
Rudd et al. 261
Internet in the dissemination of warning cians will most likely be highly receptive to
such a shift, with an emphasis on empiricalsigns for suicide and found little agreement
across Web sites, with little specificity to sui- work that has direct impact on day-to-day
clinical decision making with suicidal pa-cide among the warning signs offered. For
example, most sites included were heavily tients, hence, the choice of the near-term de-
scriptor. In addition, a list of warning signsweighted with symptoms of depression as
warning signs for suicide. Depression is a risk for imminent suicide risk will be a valuable
resource for suicide hotline phone counse-factor for suicide, not a warning sign per se.
lors, a large number of whom are lay volun-
teers, as well as emergency department staff
and first responders (e.g., police and fire de-
CLOSING COMMENTS partments). Undoubtedly, many readily ac-
cepted risk factors will also prove to be im-
portant warning signs; however, an empiricalThe issue of establishing and dissemi-
nating empirically-based warning signs for foundation needs to be established first. We
have attempted to lay the foundation for suchsuicide is an important one. To a large de-
gree, empirical investigation requires a para- empirical work here by clarifying some of the
characteristic features of warnings signs anddigm shift, conceptualizing risk in immedi-
ate, acute, and chronic fashion. It will certainly offering a working definition of the con-
struct, along with identifying three domainsbe necessary to redefine short-term risk as
something far shorter than 12 months. Clini- for future research.
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