Kurt Cobain, leader of the rock band Nirvana, sometimes appeared on stage with a T-shirt bearing the words I hate myself and I want to die. He was also a heroin addict who stored several guns at home and had a family history of suicide. In 1994, he killed himself.

Beverly Cobain, Kurt's cousin and a psychiatric nurse, knew for years before he died that Kurt was in trouble. She still asks herself: "Could his pain and risk for suicide have been made any clearer? Why hadn't I done more?"

Thousands of people could ask the same question. In spite of nationwide prevention efforts, suicide rates in the United States have declined just slightly since 1990, from 12.4 per 100,000 in 1990 to 10.7 per 100,000 in 2003. According to the U.S. Center for Disease Control and Prevention, 31,484 Americans took their own lives in 2003. Suicide is the third-leading cause of death among people ages 15 to 24. The risk of suicide in alcoholics is 50 to 70 percent higher than for the general population.

Such figures only hint at the depth of the problem. According to the National Institute of Mental Health, there may be between 8 and 25 attempted suicides for every suicide death.

One reason that suicide is so difficult to prevent, says Cobain, is that the subject is still surrounded by a constellation of myths. For example:

• People have to be clinically depressed before they're at risk for committing suicide.
• When a distressed person's behavior suddenly improves, the danger of suicide is over.
• Talking openly about this subject with someone who's distressed can cause that person to commit suicide.

"I no longer believe that one must be clinically depressed in order to think of--or attempt--suicide," Cobain says in response to the first myth. "One simply needs to have such pain and turmoil in their lives that the only option they see to free themselves is to die."

Edwin Shneidman, professor emeritus of thanatology (the study of death) at the University of California, Los Angeles, and an expert on suicide, uses the term "psychache" for this state of mind. A strong link exists between depression and suicide, and depressed individuals should absolutely be identified and treated for their illness, says Cobain. "But as we have seen, suicide is a matter of unbearable psychache plus the simultaneous idea of death as the only solution."

Sometimes people at risk for suicide suddenly experience an improved mood. Relatives and friends might then assume that the crisis point has passed. Yet this too often is another myth, says Cobain. The seeming change for the better may result from the person's silent decision to finally take his or her own life in the near future--and thus be rid of psychache forever.

Talking openly about all this does not increase the risk of suicide. In fact, Cobain says, such conversation can be the simplest, most effective way to prevent the act. In their new book Dying to Be Free: A Healing Guide for Families After a Suicide (Hazelden, 2006, $12.95), Cobain and Jean Larch, a social worker and crisis intervention specialist, offer strategies for having this talk.

The key is to communicate the fact that you want to hear the truth. This means avoiding questions such as, "You're not thinking of suicide, are you?"

Instead, Cobain and Larch urge readers to bring up the problem in a nonjudgmental way that gives people permission to "speak the unspeakable." For example: It's okay to say, "Have you been having suicidal thoughts?"

If the answer is yes, don't panic, listen calmly, and don't argue. Cobain and Larch suggest letting the person say everything he or she has to say. Don't try to fix the person. Do not discount the person's feelings. Tell the person he or she must be hurting to be considering suicide. Be caring and compassionate. And explore options other than suicide: Ask if there is a trusted person who can help. If not, suggest 911, a local crisis line, or a hospital emergency room.

"Remember," Cobain and Larch note, "the vast majority of people do answer truthfully when asked if they are suicidal."

If you or someone you know feels suicidal, call one of the following hotlines: the National Suicide Prevention Lifeline at 1-800-273-TALK or the Crisis Connection at 1-800-SUICIDE. The American Association of Suicidology is an organization dedicated to the understanding and prevention of suicide. For more information on the book, Dying to Be Free, visit www.hazelden.org/bookstore or call 1-800-328-9000.

--Published May 29, 2006