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Discussion and conclusions Suicidal individuals have many unmet needs, and they may not fit into diagnostic categories and may lack a full clinical picture. They should not be left alone with no treatment as if therapeutic options would prove to be of no use. Psychological pain, as a main ingredient of suicide, is the pain of excessively felt shame, guilt, fear, anxiety, loneliness, and angst. This very human condition points to the fact that the nature of suicide is first mental, mean- ing that each suicidal drama occurs in the mind of a unique individual [19]. Depressed individuals are suicidal only when negative emotions are so painful that suicide is the only option left and when the suicidal mind is hosted in an individual’s depressed brain. Such individuals con- clude that life cannot be accepted with unbearable suf- fering. Suicide is not, therefore, a specific and narrow symptom of depression. Instead, it is a behavior “com- bining features of a declaration of war with a petition for bankruptcy” [20]. What emerged from the case reported above is the fact this man was experiencing a narcissistic failure from hav- ing his business closed down, and his employees fired. He was between life and death, hoping somebody would rescue him and reduce his suffering. From the clinical picture, there also emerged a feature always traceable in suicidal individuals, that is, ambivalence. He was contem- plating suicide, but he also was attached to life’s activi- ties, such as his duties and his family, and he ultimately phoned a friend. This feature can be a crucial element in suicide prevention, providing a period available for rescuing the individual in crisis. During this phase, sui- cidal individuals often communicate, either covertly or explicitly, their intention to die [21]. The suicidal crisis is also often anticipated or accompanied by three symp- toms: anxiety (inner turmoil), agitation and irritabil- ity [22], key features also found patients with depressive symptoms during mania [23]. Sleep symptoms are often reported occurring well before the emergence of the sui- cidal ideation. People contemplating suicide, but experi- encing ambivalence, often consider what has been crucial in their lives. They may give away books, jewelers, and symbolic objects to someone who will take care of such things after their death. From the case report above, we learn that two other essential items were at work in the suicidal mind: hope- lessness (such as not having positive future expecta- tions) and dramatic mood changes. Hopelessness has been reported as more indicative than depression in the prediction of suicide [24, 25]. The patient, although con- tinuing to work, saw no future in his activity, dismiss- ing claims for payment as something, which he would not deal with anymore. He also alternated pessimistic thoughts with some recreational activities. Of note is that, before the final decision to die and collecting the gun, he had experienced a good mood and a state of enjoyment (playing golf with friends). Suicidal individu- als often switch from sadness to positive and enthusi- astic thinking, a feature that has been interpreted with having decided to die by suicide and eliminating the ambivalence. What causes suffering is the ruminations and thoughts that reiterate the failures, the shame, the loss and the rejections (to name just a few) so that imag- ining the abolition of the flow of thoughts in the con- scious mind is seen as the ultimate relief. Clinicians must explore death fantasies in suicidal individuals. When sui- cide risk is deemed to be high, I always ask if the patients have ever thought about his or her afterlife, that is, the funeral, who will attend, or the reaction of the people who will discover the body. In highly suicidal individuals, such fantasies are reported, whereas they often (although not always) evoke horror if the risk of suicide is low. Clinicians who consider suicidal ideation to be merely a symptom of depression may miss the rare opportunity to get to know a very private aspect of patients and reduce their suffering. They may even uncover the fact that what they are treating is not necessarily major depression with suicidal ideation but rather severe human sadness emerg- ing with suicidal wishes. This critical distinction may dra- matically change the outcome for patients. Treatments and therapeutic options depend on the clinical mani- festations. Clinicians may use available treatments for targeting symptoms such as insomnia, agitation, and dys- phoria. At the same time, major depression with suicidal ideation may benefit from both pharmacological and non-pharmacological interventions, while not ignoring Pompili Ann Gen Psychiatry (2019) 18:7 Page 4 of 5 the motives for wishing to be dead which should be at the center of the psychiatric intervention. Modern psychiatry needs a better interpretation of suicide risk as compared with old models and reduction- ist explanations of a complex phenomenon. Rather than confining suicidal ideation to the realm of a symptom, clinicians should relocate such event in the complexity of each human being. Defining it as a symptom inevitably suggests that it is a manifestation of a given disease. We are however dealing with disorders rather than diseases, and suicidal ideation may emerge from the unfortunate combinations of various factors that threaten the stability of an individual. The result of such a state may belong to a different domain than the criteria of major depression. Despite the centrality of perspectives derived from genet- ics and epigenetics, neurobiology, psychobiology, far from being a manifestation of “normality,” suicide risk is ultimately a manifestation of overwhelming mental pain for which clinicians should be able to provide relief. Such clinical task reveals that suicidal impulses (thoughts and actions) are better understood as a pervasive condition whose roots originate from the internalization of pain- producing inner patterns derived from unsolved past experiences. Such vicissitudes influence proximal risk factors for suicide and exacerbate reactions to present adverse events. Notions presented in this paper are in line with sig- nificant campaigns for preventing suicide, which point to the fact that any single factor rarely causes suicide. Fac- tors can include relationship problems, substance misuse, a recent crisis as well as job, financial or legal stress [4]. Furthermore, recent results highlight the role of child- hood traumatic experiences in determining vulnerability to both depression [26] and suicide [27]. Recent find- ings demonstrated that childhood traumatic experiences negatively influence the outcome of major depression in adulthood [28]. Besides, depressed patients who experi- enced trauma in childhood may be less likely to respond to treatment and achieve remission [29]. Such evidence goes to show that the focus is the person rather than the disorder and that a comprehensive analysis of both clini- cal assessments of major depression according to psy- chiatric criteria as well as an empathic understanding of what energizes mental pain is the key role of anyone who is professionally involved in helping such suicidal individuals. Clinicians should put themselves into the shoes of the individual with whom they are dealing with. They should discern whether it is major depression or sadness and misery derived from accumulating adverse events. A more phenomenological approach would be of help in assessing the suicidal risk formulation in patients with major depression. Abbreviation DSM-5: Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Acknowledgements None. Disclosures Nor the author or immediate family member has financial relationships with commercial entities that might represent the appearance of a potential conflict of interest. No competing interests as related to this manuscript. The Ethics approval and consent to participate does not apply to this submission. Authors’ contributions The author read and approved the final manuscript. Funding None. Availability of data and materials Not applicable. Ethics approval and consent to participate Not applicable—material presented in the case report has been disguised to preserve patient confidentiality according to Clifft, M.A. (1986). Writing about psychiatric patients. Guidelines for disguising case material. Bulletin of The Menninger Clinic, 50, 511–524.; also, the patient released the original story through mass-media and gave it to the public domain;