Suicidal ideation and suicide in MS

Mental health problems and suicide are the elephant in the MS consulting room.

As you are aware, I am writing Books 2 and 3 of the MS-Selfie self-management guide (Book 1 is online). I am hoping to complete the books by the end of the year. My aim is to complete all the stops on the holistic management of the MS map, based on the London Underground.

One topic that has come up as part of the issues of mental health is suicidal ideation and suicide. So this is my attempt to discuss the underbelly of MS in a way that is not too dark. Yes, I am wearing rose-tinted glasses, but the content may still upset you. This newsletter was triggered by a recently published systematic review on the subject, which I used as my main reference.

Suicidal ideation and suicide in MS

People with MS (pwMS) know MS is a chronic, unpredictable, and often disabling neurological condition, and as a result, they carry a psychological burden that is usually overlooked in a busy 15-minute annual outpatient appointment. Mental health problems and suicide are the elephant in the MS consulting room. They sit quietly alongside the disability progression conversation, the DMT switch discussion, and the “how are things at home?” question that HCP often forget to ask.

A landmark study by Dessa Sadovnick, George Ebers and colleagues in 1991 found that suicide was the third most common cause of death among pwMS attending MS clinics, and more recent work suggests that the suicide rate in pwMS is roughly twice that of the general population. Suicidal ideation (SI) — thoughts of ending one’s life, with or without a plan — is the single most important precursor to suicide attempts and death by suicide, and is far more common than most HCPs appreciate.

A new systematic review and meta-analysis (Bazmi et al. 2026) pulls together 18 studies and more than 8,000 pwMS to provide a picture of how common SI is in MS, what drives it, and where the gaps are in MS care.

How common is suicidal ideation in MS?

Bazmi and colleagues estimate the pooled global prevalence of SI in pwMS to be 20% (95% CI, 15–25%). In other words, roughly one in five people sitting in an MS clinic waiting room has had thoughts of suicide. This is higher than the 13% figure from an earlier 2020 meta-analysis, and the authors suggest two plausible explanations: an expanding evidence base that now includes more diverse settings, and a real rise in SI rates — perhaps linked to the COVID-19 pandemic, growing geopolitical instability, and reduced stigma around reporting mental health symptoms.

Individual study prevalence ranged dramatically, from 8% in a Canadian cohort to 36% in an Iranian cohort. This is probably not just noise and is telling us something important about how context, culture, income level and healthcare infrastructure shape suicide risk.

Regional and temporal patterns

High-income countries reported a pooled SI prevalence of 17%, compared with 32% in upper-middle-income countries (represented in the review by three studies from Iran and one from Brazil). This is a near doubling of risk, and it aligns with what we know about mental health inequities more broadly — poverty, housing insecurity, financial strain, limited access to psychiatric services, and stigma all conspire to worsen outcomes in lower-resource settings. All “developing country” data in this review came from just two countries; therefore, we should be cautious about extrapolating the findings to sub-Saharan Africa, South Asia, or Latin America as a whole.

SI prevalence was 30.5% in the single 1990s study, 29.2% in studies from 2000–2009, 18.7% in studies from 2010–2019, and 17.2% in studies from 2020–2025. At face value, this looks encouraging — perhaps reflecting better recognition of depression in MS, earlier initiation of disease-modifying therapy, and broader mental health awareness. But this is no reason to be complacent. The 2020–2025 figure still means roughly one in six pwMS has active suicidal thoughts, and global crises in the last five years may be masking an underlying deterioration that will only become visible in the next generation of studies.

How does this compare with the general population?

In most high-income countries, lifetime SI prevalence in the general population is around 9–10%, and 12-month prevalence is around 2–3%. The 20% figure in MS is therefore roughly double that seen in the background population — a finding echoed by multiple independent cohort studies.

Who is at risk? The anatomy of suicidal ideation in MS

No single risk factor predicts SI in isolation. Suicide is the final common pathway of several biological, psychological and social factors. The Bazmi review identifies consistent drivers that can be grouped into four domains.

1. Psychiatric comorbidity: depression and anxiety

Depression and anxiety are the most consistently reported risk factors for SI in MS, identified in 13 of the 18 studies in the review. Depression affects up to 50% of pwMS at some point, and a meta-analysis reports a pooled prevalence of 20.6% for clinical depression and 35% for moderate-to-severe depressive symptoms. These rates substantially exceed those in the general population (14–21%).

• Neuroinflammatory and neuroendocrine mechanisms (depression in MS is not simply a “reaction” to having MS — it has a biological basis)

• Lesion location, particularly in limbic and frontal pathways

• Disease-modifying therapy side effects (interferon therapy in particular has a well-described association)

• The psychological burden of uncertainty, disability and loss of role

Anxiety, which is often under-recognised and under-treated in MS, frequently coexists with depression and independently elevates SI risk.

2. Disease-related factors

Several disease features track with SI across studies:

• Greater disability — measured both by clinician-rated EDSS and by self-reported physical impairment. Self-reported disability may actually be a stronger predictor than EDSS, because it captures the subjective experience of living with impairment.

• Longer disease duration — though this relationship is complex. Some studies have found a positive association, and others have found the opposite, suggesting psychological adaptation over time in some patients. I suspect it depends on whether the pwMS is able to cope with living with MS or is demoralised.

• Progressive MS — higher SI rates are found in people with more advanced MS when compared with the earlier relapsing-remitting phase. This likely reflects accumulated disability and the impact of therapeutic nihilism. Yes, many HCPs and healthcare systems think that once someone with MS becomes disabled, the disease is not modifiable. I hope the ocrelizumab in PPMS (O’HAND study), siponimod in SPMS (EXPAND study), tolebrutinib in non-relapsing SPMS (HERCULES study) and the fenebrutinib in PPMS (FENTREPID study) change this perspective.

• Specific symptoms — fatigue, sleep disturbance, spasms, bladder and bowel difficulties, and speech and swallowing problems also correlate with SI. As a group, these symptoms erode quality of life.

3. Sociodemographic factors

The evidence here is more mixed:

• Age — findings are inconsistent. Some studies identify older patients (≥65) as higher-risk; others find younger pwMS more vulnerable. My clinical intuition is that both extremes carry risk for different reasons — younger patients with recent diagnosis face a challenge to their identity and loss of envisioned future, while older patients face accumulated disability and social isolation.

• Male sex — some (but not all) studies find men at higher risk, consistent with general population data on completed suicide.

• Unmarried status and living alone are both associated with increased SI in multiple studies.

• Education level — this is complex and possibly bidirectional. Most studies suggest that higher educational attainment is protective (e.g., better health literacy, coping strategies, economic resources), but one Iranian study found the opposite, perhaps reflecting unmet expectations or awareness of prognosis.

4. Social and existential factors

This is the domain that is easiest to miss in a busy MS clinic and most important to address:

• Low perceived social support — from family, friends and significant others — is a consistent risk factor.

• Loneliness and social exclusion — “feeling socially excluded” strongly correlates with SI.

• Hopelessness and loss of purpose — perceived loss of control, loss of masculinity/femininity, and failure to achieve an expected role contribute psychologically to SI.

• Loss of faith or spiritual meaning — having a sense of purpose and comfort in faith (in those for whom it is relevant) is protective. This is why religion and church membership are helpful.

• Financial strain and anticipated stigma — this is particularly important in lower-resource settings.

Screening for suicidal ideation in the clinic

If 20% of pwMS experience SI but only a small fraction volunteer it spontaneously, systematic screening is not optional and should be part of the basic standard of care. Effective screening tools exist, and they only take a few minutes to complete.

The Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is the most practical and widely validated tool for MS. It is a 9-item self-report depression screen, and item 9 specifically asks about thoughts of self-harm or being better off dead. The PHQ-9 is specifically for SI detection in people with neurological conditions, including MS. It takes under 3 minutes to complete and can be completed in the waiting room or electronically before the clinic. Scores above 10 indicate clinically significant depression warranting action. A positive response to item 9 should trigger a suicide risk assessment. It could be argued that every MS clinic should administer the PHQ-9 at least annually, and at every unscheduled visit where there has been a relapse, a significant disability progression, a DMT change, or a major life event. I would be interested to know if you have ever completed a survey of this kind.

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Some of you may have already seen a spreadsheet of factors to consider and document before your annual follow-up assessment. This is in the form of a Google sheet, but can be downloaded as an Excel spreadsheet. The spreadsheet has four tabs or sheets. The ‘About’ tab tells you about the tool. The ‘Annual Review’ records your information and adds it to the ‘History’ tab. The ‘Trend’ tab plots the changes in your outcomes over time. Finally, the ‘Scale Guide’ provides information about the PROMS (patient-related outcome measures) I have included in the tool. I think I need to add the PHQ-9 to the spreadsheet now. Do you agree?

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The Beck Scale for Suicide Ideation (BSI)

The BSI is a 21-item instrument designed specifically for suicide risk. It is more detailed than the PHQ-9 and is better suited to psychiatric follow-up than first-line screening.

The Beck Depression Inventory-II (BDI-II)

The BDI-II is a broader depression measure that includes a suicide item. This is often used in research settings but takes longer to complete than the PHQ-9 in a clinic.

The Hospital Anxiety and Depression Scale (HADS)

The HADS is my favoured alternative that captures both anxiety and depression domains, but does not include a direct suicide item, so a positive HADS should always prompt a follow-up suicide-specific question.

What should you be asked if a screen is positive?

Clinicians often feel awkward asking directly about suicide. Evidence is unambiguous in that

1. “Have you had thoughts that life isn’t worth living, or that you’d be better off dead?”

2. “Have you had thoughts of harming yourself?”

3. “Have you thought about how you might do it?” (plan)

4. “Do you have access to the means?” (access)

5. “Have you taken any steps or made any preparations?” (intent)

Presence of a plan, access to means, or preparatory behaviour indicates a high imminent risk and demands urgent psychiatric referral — ideally, the same day.

Prevention: what can we actually do?

Prevention in MS operates at three levels: the clinic, the patient, and the system.

At the clinical level

1. Screen systematically. A good MS service should embed PHQ-9 into routine MS review and should not rely on patients volunteering SI. When I was doing routine MS clinics, I was guilty of not implementing this, something I would change if I were setting up an MS clinic now. I will also add this to the annual routine questionnaire that must be completed before each clinic visit.

2. Treat depression and anxiety aggressively. Depression and anxiety are the dominant modifiable risk factors. SSRIs (sertraline, citalopram, escitalopram) are first-line, well-tolerated, and have no meaningful interaction with current DMTs. CBT — including web-based CBT — has good evidence base in MS. Reject the dogma that “of course they’re depressed, they have MS” as a reason not to proactively manage depression.

3. Address symptom burden. Fatigue, pain, sleep disturbance, bladder dysfunction and spasticity are not just quality-of-life issues — they are suicide risk factors that need to be treated. Don’t let your HCP fob you off.

4. Be alert at transition points. Diagnosis, relapse, disability milestones (losing the ability to walk, work, or drive), DMT failure, and being labelled as having secondary progressive MS are all periods of elevated risk.

5. Assess social support explicitly. Who do you live with? Who helps you? Who would you call at 3 am? Loneliness and social isolation should be treated as vital signs.

6. Restrict means where appropriate. Safe storage of medications, particularly in patients with large prescribed quantities of opioids, benzodiazepines or anticholinergics, can save lives. This conversation needs to be had with the pwMS, their partner, and family.

7. Document and communicate risk. A named crisis contact, a safety plan, and communication with the GP or primary care physician should be standard practice.

At the patient and family level

1. Psychoeducation. Many pwMS don’t know that depression is a common and treatable part of MS — they assume sadness and hopelessness are inevitable. Naming and confronting depression and SI helps.

2. Normalise help-seeking. The stigma of psychiatric care in MS remains real. Framing mental health as part of MS care, not something separate, reduces that barrier.

3. Involve family. Family members are often the first to notice a change — withdrawal, giving away possessions, changes in sleep. They need to be taught about what to watch for.

4. Build purpose and connection. Peer support groups (MS Society, MS Trust, MS International Federation resources), vocational rehabilitation, social prescribing, church attendance, volunteering and hobbies all buffer against hopelessness. Having a purpose in life and being productive is negatively correlated with SI.

5. Safety planning. A written safety plan — warning signs, coping strategies, people to call, reasons for living, means restriction — is a simple but evidence-based intervention. The Stanley-Brown Safety Plan is freely available online.

At the system level

1. Integrate mental health into MS services. A neuropsychologist or clinical psychologist embedded in an MS service should not be a luxury; it is the minimum standard for a condition where one in two patients develops depression. That said, most NHS MS clinics don’t have a neuropsychologist embedded, and referring pwMS for assessment and management takes time.

2. Address inequity. The doubled SI prevalence in middle-income countries is not inevitable. It reflects under-resourced mental health services, stigma, and financial barriers to care — all modifiable at a policy level.

3. Research underrepresented populations. The Bazmi review openly discusses its limitations: there is no data from low-income countries, and no data from most of Asia, Africa, or Latin America beyond a single Brazilian study. Global MS care cannot be evidence-based if the evidence is dominated by findings from high-income countries. This is why more research is needed.

A few honest caveats

This review below has limitations that need to be acknowledged. Study methodologies vary widely: SI is measured with different instruments and at different time points; diagnostic criteria for MS are inconsistently reported; heterogeneity between studies is high. The "20% prevalence" figure is therefore an estimate with uncertainty. What is

The bottom line

If you are an HCP and are reading this, please remember that one in five of your MS patients has had thoughts of suicide. Most of them have not told you. The dominant drivers — depression, anxiety, disability, symptom burden, loneliness, hopelessness — are either treatable or modifiable, and the screening tools are simple, brief and validated. Suicide in MS is not inevitable. It is, however, easy to miss. Every person with MS deserves a clinician who asks directly, listens without flinching, and acts on what they hear.

Key paper

Bazmi E, Behnoush AH, Mohammadi Lapevandani M, Talebian MT, Jahani S, Sahraian MA. Global Prevalence and Risk Factors of Suicidal Ideation in Multiple Sclerosis: A Systematic Review and Meta-Analysis.

Background and aims: Suicidal ideation (SI), attempts, and death have been frequently described and investigated in chronic neurological disorders such as Multiple Sclerosis (MS). This systematic review and meta-analysis estimated the global prevalence of SI in patients with MS and demonstrated associated risk factors. This may help the physician to reduce the rate of suicidal attempts and improve public health.

Methods: A comprehensive systematic search was performed on PubMed, Scopus, Embase, and Web of Science to find studies that reported the prevalence of SI or its related factors in MS patients. Studies were screened by the title/abstract and then by their full text. Data extraction was performed for relevant studies. A point prevalence with a 95% confidence interval was estimated. Random-effect meta-analysis was conducted to assess the pooled prevalence of SI.

Results: From the 1246 total studies that were found, we included 18 final eligible studies for systematic review and 16 studies for meta-analysis. The prevalence of SI in multiple sclerosis patients was estimated at 20% (95% CI [15-25]), based on random-effect meta-analysis. Among the included studies, higher rates of depression and anxiety, lower family and social support, longer duration of illness, and higher levels of disability were related risk factors for SI in patients with MS.

Conclusion: Given the higher prevalence of SI in people with MS than in the general population, it should be considered during routine clinical visits and psychological evaluations. Proper counselling, psychological support, and psychiatric interventions may reduce the lifetime risks and help patients overcome their suicidal thoughts.

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