OBJECTIVE: This study attempted to assess whether an index of the difference between the wish to die and the wish to live constitutes a risk factor for suicide. METHOD: A study group of 5,814 patients, including 44 who committed suicide (0.8%), were recruited from a psychiatric outpatient clinic. Structured diagnostic interviews and clinician ratings of the wish to live and wish to die were conducted. The outcome variable was the occurrence of suicide, as indicated on death certificates. RESULTS: A dichotomized index score of the difference between the wish to live and the wish to die yielded a hazard ratio of 6.51 for suicide. This index contributed a unique risk for suicide after the authors controlled for age, psychiatric hospitalization, suicide attempts, bipolar disorder, major depressive disorder, and unemployment status. CONCLUSIONS: The difference between the wish to die versus the wish to live is a unique risk factor for suicide.