FROM THOUGHT TO CONTEMPLATION TO PREPARATION TO ACTION
A survey of Mental health and well-being in England (2014) found one in five adults in England report experiencing suicidal thoughts at some point in their lifetime. Kessler et al (1999) found 13.5% of participants in a national survey of 5,877 people reported lifetime ideation, 3.9% a plan and 4.6% an attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72% from a plan to an attempt and 26% from ideation to an unplanned attempt. About 90% of unplanned and 60% of planned first attempts occurred within one year of the onset of ideation. All significant risk factors were more strongly related to ideation than to progression from ideation to a plan or an attempt. Suicidal ideation substantially increases the odds of future suicide attempts (Harris & Barraclough 1997) but suicide is far from inevitable, thus providing an important window for intervention and suicide prevention. The majority of those who attempt suicide do not die by suicide; less than 10% of people who attempt suicide die by suicide (Owens et al 2002). However, rates of death by suicide increase in those who make repeated and life-threatening attempts (Paris 2006). Individuals are at the highest risk of repeating a suicide attempt during the first three months following their first suicide attempt (Monti et al 2003).
The World Health Organizations World Mental Health Survey Initiative studied 84,850 people from the general population in 28 countries to identify any association between suicidal thoughts and plans and suicidal behaviour (Nock et al 2008). It found that 29% of people with suicidal thoughts went on to make a suicide attempt, 60% within a year of onset of suicidal thoughts. If those people who were experiencing suicidal thoughts also had a well-formed plan, they were far more likely to engage in suicidal behaviour. Individuals with a suicide plan had a 56% probability of making a “suicide attempt” whilst those without a plan had a 15.4% probability of a “suicide attempt”. The strongest risk factor for acting on suicidal thoughts in high-income countries was a mood disorder, particularly if accompanied by substance misuse or stressful life events. Impulsivity alone did not predict suicide but may have increased the risk of a patient acting on suicidal thoughts. This cross-national study also found among individuals with a lifetime history of suicidal ideation, the probability of ever making a plan was approximately 33%, and the probability of ever making a suicide attempt was approximately 30%.
Nock et al (2009) found episodes of suicidal ideation tend to be brief, with participants reporting most episodes are shorter than an hour. They also found that thoughts of suicide were distinct from thoughts of non- suicidal self-injury (NSSI), and co-occur less than half the time, even among those who frequently engage in NSSI. Kleiman et al (2017) confirmed that suicidal ideation is typically episodic, with a quick onset. However, some people do experience persistent, low-level suicidal ideation. In my experience this can be the case for people with enduring mental health problems. The severity of suicidal ideation varies considerably over a short period of time and between individuals (Kleiman & Knock 2018).
Cummings and Cummings (2012) see suicide as a three-stage process and argue for the relevance of timely psychological interventions. They propose that stage 1 is the “ideation” stage, during which a person finds him- or herself thinking about suicide more and more. However, the fear of suicide still outweighs its attraction. The person may be thinking dark thoughts (“my family would be better off without me”) but has not yet begun to formulate a specific plan. People in stage 1 are not at acute risk; psychological therapy will be helpful and may be sufficient. This stage may last indefinitely or may escalate to stage 2. Stage 2 is the “planning” stage, during which the person begins to formulate a specific plan for suicide. Friends and family may notice the person’s mood lowering or them withdrawing. People in stage 2 are in critical need of effective psychological care. Stage 3 begins when the suicidal person makes the decision to end their life. People in stage 3 are at imminent high risk, but may appear low risk as they experience relief and potentially a lift in mood as they see an end to their suffering and feel some sense of control. Cummings and Cummings suggest that instead of relaxing, we should become more vigilant and watch closely for any indication that the individual has decided to end their life and caution us to be alert when a depressed patient has a lift in mood. Because biological or “vegetative” features of depression may respond sooner to medication than cognitive features, they strongly recommend that antidepressant medication should never be used as a stand-alone treatment for suicidal depression. Bryan et al (2015) concluded that individuals move along the continuum of risk from suicidal ideation to plan (34%) and from ideation to attempt (29%), with most suicide attempts occurring during the first year after the onset of suicidal ideation.
Evaluating the pattern of suicidal ideation in each individual is critical to understanding, formulating and helping them reduce their risk.
Suicide rehearsals (mental or behavioural) may precede suicide or attempted suicide. A suicide rehearsal is a mental or behavioural enactment of a suicide method, usually as part of a suicide plan. Rehearsing suicidal behaviour can lower the barrier to a suicide plan, thereby increasing a patient’s resolve and risk. Joiner (2005) argues that engaging in behavioural or mental suicide rehearsals increases the risk of suicide.
Rehearsing suicide (Simon 2012) is likely to:
- • diminish the prohibition against suicidal behaviour and the fear of pain and dying;
- • reduce ambivalence about dying;
- • desensitise anxiety about performing the suicide act;
- • test or “perfect” the method of a planned suicide;
- • firm one’s resolve to carry through suicide.
Studies suggest mental rehearsal of suicide is associated with suicide attempts and death by suicide (Buchman 2015).