Psychiatrist Dr. Isaac Efraim has said that mental health care needs to focus on the invisible warning signs that build up before depression drives someone toward suicide, rather than waiting until a person speaks of wanting to die. Writing for Brazil's Yellow September suicide prevention campaign, he argued that the extreme act itself is usually the final stage of a mental process of self-destruction that began much earlier.
According to Efraim, that earlier process is the one society needs to learn to recognise and interrupt, because by the time someone verbalises an intention to die, the psychological groundwork has often been laid for some time.
How the Mind Turns Events Into Suffering
Efraim said the human mind does not simply record reality, it interprets it. The same event can take on completely different meanings depending on a person's past experiences, memories and mental patterns, he said, and much of psychological suffering develops in the gap between what actually happened and what the mind builds around it.
He gave examples of real events, a loss, a rejection, a professional failure, a separation or a humiliation, that the mind can turn into far more devastating conclusions, such as believing one's life is over, that everything has been ruined, that there is no way out, or that nothing will ever improve. Over time, Efraim said, a person stops suffering only because of what happened and begins suffering because of the scenario their own mind has constructed on top of it.
When Reality Narrows
This is where what Efraim called a dangerous phenomenon begins: the narrowing of reality. He said the alternatives a person has do not actually disappear, but the person stops being able to see them. The future starts to look like the same repeating scene, pain today, pain tomorrow, pain after that, and a mental image repeated often enough can take on, for the person suffering, the weight of reality itself.
In some people, Efraim said, this turns against the self. Guilt stops being simply "I made a mistake" and becomes "I am a mistake." He said the difference looks small but is enormous, because recognising an error still allows a person to correct it, learn from it and move on, while turning a failure into an identity traps them. He said his own research on guilt traces exactly this shift, from guilt to shame and, in more serious cases, from internal punishment to self-destructiveness.
The Internal Tribunal
Efraim described the result as a kind of internal tribunal that runs constantly, with the same person acting as accuser, defendant and judge. That person holds themselves to what they believe they should have been, done or achieved, he said, and there is no escaping this creditor because the creditor and the debtor live in the same mind. The more a person punishes themselves, the less psychological energy they have to rebuild their life, and the less they can rebuild, the more reasons they find to punish themselves further, a cycle that feeds itself.
Because of this, Efraim said it is inaccurate to describe someone who thinks about acting against themselves as simply wanting to die. He said what that person desperately wants, in many cases, is for a particular experience of suffering to end. Death appears, to a mind that has become progressively cornered, as a solution to stop the pain. He called the distinction crucial for prevention: not finding a way out is very different from there being no way out.
Why 'Think Positive' Doesn't Work
Efraim said this is also why phrases such as "think positive," "you have everything to be happy about" or "look at how many people have worse problems" tend to fail. He said they argue with the conclusion a person has reached without engaging with the process that produced it. The task, he said, is not to convince someone their life is wonderful, but to help them see that the scenario occupying their mind at that moment is not the whole of reality. The suffering is real, he said, but the belief that it will last forever is not necessarily true.
Early Warning Signs
Efraim said preventing the extreme act that depression can lead to does not begin only when someone says they intend to die. It begins much earlier, when people notice growing isolation, hopelessness, guilt that has turned into identity, a sense of being a burden, the repetition of mental scenarios with no exit, and a progressive loss of the ability to imagine a different future. The earlier that cycle is interrupted, he said, the greater the chance of giving the person back something their suffering has taken from them: perspective.
Efraim said the most important message may be that, at the height of a suicidal crisis, it is not necessarily life that has run out of possibilities, but the mind that has temporarily lost the ability to see them. He said that distinction changes everything, because what has been built inside the mind can be understood, treated and transformed. Between pain and self-destruction, he said, there is a space, and it is in that space that others, care, treatment and a new possibility of a future need to enter.
The article was published as part of Yellow September, Brazil's national suicide prevention campaign held each September, which coincides with World Suicide Prevention Day on 10 September. Efraim is a psychiatrist registered with Brazil's regional medical council in São Paulo, CRM/SP 38124, with specialist registration RQE 33307.
