Updated Jan. 25, 2021

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.

The pandemic has taken a heavy emotional toll on many people, and if you know someone struggling with despair, depression or thoughts of suicide, you may be wondering how to help.

Many Americans — children and teens in particular — are finding these feelings have worsened in the pandemic. Hospital emergency departments saw a rise between March and October in the number of children in mental health crisis.

Most Americans recently surveyed say that they understand that suicide is preventable and that they would act to help someone they know who is at risk.

Yet many of us are afraid to do the wrong thing. In fact, you don't have to be a trained professional to help, says Doreen Marshall, a psychologist and vice president of programs at the American Foundation for Suicide Prevention.

"Everyone has a role to play in suicide prevention," she says. But "most people hold back. We often say, 'Trust your gut. If you're worried about someone, take that step.' "

And that first step starts with simply reaching out, says Marshall. It may seem like a small thing, but survivors of suicide attempts and suicide experts say, it can go long way.

Simple acts of connection are powerful, says Ursula Whiteside, a psychologist and a faculty member at the University of Washington School of Medicine.

"Looking out for each other in general reduces [suicide] risk," says Whiteside. "Because people who feel connected are less likely to kill themselves."

And "the earlier you catch someone," she adds, "the less they have to suffer."

Here are nine things you can do that can make a difference.

1. Recognize the warning signs

Signs of suicide risk to watch for include changes in mood and behavior, Marshall says.

"For example, someone who is usually part of a group or activity and you notice that they stop showing up," explains Marshall. "Someone who is usually pretty even-tempered and you see they are easily frustrated or angry."

If you're only seeing your loved ones virtually because of the pandemic, pay attention if they start withdrawing from virtual spaces, too, says Whiteside.

Maybe "they're not responding to phone calls or they're not joining in on a call with family or they're not on social media," she says. "That's one time that it makes sense to get curious about what's going on with your friend — when people start to disappear."

Other signs include feeling depressed, anxious, irritable or losing interest in things.

Pay attention to a person's words, too.

"They may talk about wanting to end their lives or seeing no purpose or wanting to go to sleep and never wake up," says Marshall. "Those are signs that they may be thinking about [suicide]. It may be couched as a need to get away from, or escape the pain."

According to the AFSP, people who take their own lives often show a combination of these warning signs.

And the signs can be different for different people, says Madelyn Gould, a professor of epidemiology in psychiatry at Columbia University who studies suicide and suicide prevention.

"For some people, it might be starting to have difficulty sleeping," she says. Someone else might easily feel humiliated or rejected.

"Each one of these things can put [someone] more at risk," explains Gould, "Until at some point, [they're] not in control anymore."

2. Reach out and ask, "Are you OK?"

So, what do you do when you notice someone is struggling and you fear they may be considering suicide?

Reach out, check in and show you care, say suicide prevention experts.

"The very nature of someone struggling with suicide and depression, [is that] they're not likely to reach out," says Marshall. "They feel like a burden to others."

People who are having thoughts of suicide often feel trapped and alone, explains DeQuincy Lezine, a psychologist and a member of the board of directors of the American Association of Suicidology. He is also a survivor of suicide attempts.

When someone reaches out and offers support, it reduces a person's sense of isolation, he explains.

"Even if you can't find the exact words [to say], the aspect that somebody cares makes a big difference," says Lezine.

Questions like "Are you doing OK?" and statements like "If you need anything, let me know" are simple supportive gestures that can have a big impact on someone who's in emotional pain, explains Julie DeGolier, a medical assistant in Seattle and a survivor of suicide attempts. It can interrupt the negative spiral that can lead to crisis.

The website for the National Suicide Prevention Lifeline has a list of do's and don'ts when trying to help someone at risk.

3. Be direct: Ask about suicide

"Most people are afraid to ask about suicide, because they [think they] don't want to put the thought in their head," says Marshall. "But there's no research to support that."

Instead, she and other suicide prevention experts say discussing suicide directly and compassionately with a person at risk is key to preventing it.

One can ask a direct question like, "Have you ever had thoughts of suicide?" says Marshall.

More general questions like, "What do you think of people who kill themselves?" can also open up a conversation about suicide, says Gould. "Now they are talking about it, when you might not have had the conversation before."

4. Assess risk and don't panic: Suicidal feelings aren't always an emergency

Say a loved one confides in you that they have been thinking about suicide, what do you do then?

"Don't let yourself panic," says Whiteside.

People often believe that a person considering suicide needs to be rushed to the hospital. But "not everyone who expressed these thoughts needs to be hospitalized immediately," says Marshall.

Research shows that most people who've had suicidal thoughts haven't had the kind of overpowering thoughts that might push them to make an attempt, explains Whiteside. In other words, many more people experience suicidal thoughts than take action on them.

But how do you know whether your loved one's situation is an immediate crisis?

Whiteside suggests asking direct questions like: "Are you thinking of killing yourself in the next day or so?" and "How strong are those urges?"

For help with this conversation, psychiatrists at Columbia University have developed the Columbia Protocol, which is a risk-assessment tool drawn from their research-based suicide severity rating scale. It walks you through six questions to ask your loved one about whether they've had thoughts about suicide and about the means of suicide and whether they have worked out the details of how they would carry out their plan.

Someone who has a plan at hand is at a high risk of acting on it — according to the Suicide Prevention Resource Center, about 38 percent of people who have made a plan go on to make an attempt.

5. If it's a crisis, stick around

So what if you've assessed risk and you fear your loved one is in immediate crisis? First, request them to hold off for a day or so, says Whiteside, at the same time being "validating and gentle."

The kind of intense emotions that might make someone act on an impulse, "usually resolve or become manageable in less than 24 or 48 hours," she says. If you can, offer to stay with them during that time period, she adds. Or, if that's hard because of the pandemic, offer to be present virtually via video call. Otherwise, help them find other immediate social support or medical help. They shouldn't be alone at these times of crisis.

Ask whether they have any means of harming themselves at hand and work with them to remove those things from their environment. Research shows that removing or limiting access to means reduces suicide deaths.

The National Suicide Prevention Lifeline offers this guide to the five action steps to take if someone you know is imminent danger.

If you don't feel confident about helping someone through a crisis period, call the National Suicide Prevention Lifeline, says Gould.

6. Listen and offer hope

If the person is not in immediate risk, it is still important to listen to them, say survivors of suicide attempts like Lezine and DeGolier.

"The biggest thing is listening in an open-minded way, to not be judgmental," says DeGolier.

"Don't tell a person what to do. They're looking to be heard, to have their feelings acknowledged."

The next step is to offer hope, says Whiteside. It helps to say things like, "I know how strong you are. I've seen you get through hard things. I think we can get through this together," she explains.

One of Lezine's closest friends in college did just that during his suicidal phases, he says.

"For one thing, she never lost faith in me," says Lezine. "She always believed I have a positive life possible and I would achieve good things."

He says her faith in him kept him from giving in to his despair completely.

"Having somebody, a confidante who absolutely believed as a person in [my] ability to do something meaningful in life" was instrumental in his recovery, he says.

7. Help your loved one make a safety plan

When a person is not in immediate risk of attempting suicide, it's a good time to think about preventing a future crisis.

"That's where we want to make help-seeking and adaptive coping strategies a practice," says Gould.

Suicide prevention experts advise people develop what's known as a safety plan, which research has shown can help reduce suicide risk. It's a simple plan for how to cope and get help when a crisis hits, and typically, an at-risk person and their mental health provider create it together, but a family member or friend can also help.

The American Foundation for Suicide Prevention has a template for creating a safety plan. It includes making a list of the person's triggers and warning signs of a coming crisis, people they feel comfortable reaching out to for help and activities they can do to distract themselves during those times — it can be something simple as watching a funny movie.

Safety planning includes helping your loved one make their environment safer. This includes a conversation about the means they would use when considering suicide, and is one of the most important steps to preventing suicide, says Marshall.

"If you ask what kinds of thoughts you're having, they may tell you the means," she says.

If they don't volunteer that information, it's worth asking them directly, she adds. Once they say what means they have thought of using, one can discuss with them how to limit their access to it.

"The more time and space you can put between the person and harming themselves, the better," says Marshall. "If this is someone who is a firearm owner, you may talk with them to make sure they don't have ready access to firearm in moments of crisis."

8. Help them tackle the mental health care system

When someone is in urgent crisis mode, it's often not the best time to try to navigate the mental health care system, says DeGolier. But to prevent a future crisis, offer to help your loved one connect with a mental health professional to find out whether medications can help them and to learn ways to manage their mood and suicidal thinking.

A kind of talk therapy called dialectical behavior therapy, or DBT, has been shown to be effective in reducing risk of suicide. It teaches people strategies to calm their minds and distract themselves when the suicidal thoughts surface.

One bright side of the pandemic is that mental health providers are doing most appointments virtually, so it has expanded access to care for many.

Still, it can be hard for someone who's struggling with negative emotions to get and keep a mental health appointment. Family members and friends can help, notes Whiteside.

"Know that it takes persistence," she says. "You don't stop until you have an appointment for them. That may mean you call 30 people until you find someone who has an availability. You take the day off from work, go with them."

Lezine says he was fortunate to have had that kind of help and support from his college friend when he was struggling.

"One of the things that was helpful ... was she went with me [to my appointment]," he says. "When you're feeling really down and feeling like you don't matter as much, you might not want to take time, or think that it's worth the time, or feel like 'I don't want to go through this.' "

Many people don't make it to their first appointment, or don't follow up, he says. Having a person hold your hand through the process, accompany you to your appointments can prevent that. This can be hard during the pandemic but get creative: Offer to drive there separately and wait nearby for them, or accompany them by video call while they wait.

"It does make a difference, making you feel like you have another person who cares," says Lezine.

9. Explore tools and support online

For those struggling to access mental health care, there are some evidence-based digital tools that can also help.

For example, there's a smartphone app called Virtual Hope Box, which is modeled on cognitive behavioral therapy techniques. Research shows that veterans who were feeling suicidal and used the app were able to cope better with negative emotions.

Whiteside and her colleagues started a website called Now Matters Now, which offers videos with personal stories of suicide survivors talking about their own struggles and how they have overcome their suicidal thoughts. Stories of survival and coping with suicidal thoughts have been shown to have a positive effect on people at risk of suicide.

The website also has videos that teach some simple skills that are otherwise taught by a therapist trained to offer DBT.

Those skills include mindfulness and paced breathing, which involves breathing with exhales that last longer than the inhales. Whiteside explains that this can calm the nervous system. Similarly, a cold shower or splashing ice water on one's face or making eye contact with someone can distract and/or calm the person who is at immediate risk of taking their own life.

Surveys show that people who visit the website and watch the videos have a short-term reduction in their suicidal thoughts, she says.

This page was originally published in Shots on April 20, 2019. It has been updated and republished.

Meghan Keane produced the Life Kit podcast version of this story.

We'd love to hear from you. Leave the Life Kit team a voicemail at 202-216-9823, or email us at LifeKit@npr.org. For more Life Kit, subscribe to the newsletter.

Copyright NPR 2021.