The Lancet publishes a comprehensive article on suicide and suicidal thinking. October 2020.
Suicidal thinking is typically discussed in one of three ways—as suicidal ideation, as suicidal intent in relation to a specific act of self-harm, or as part of a wider phenomenon of suicidality which can be taken to include thinking about or planning suicide along with actual episodes of non-fatal self-harm. Each of these three approaches raises problems of definition which we review here: we argue that resolving these problems provides one route to improving research and clinical practice in the internationally important area of suicide prevention.1Suicide has emerged as a major cause of death from non-communicable disease worldwide, leading to a burgeoning interest in its prevention. Naturally, in this context one of the focuses of research and clinical interest is the presence of suicidal thinking—a potentially identifiable and reversible precursor of suicide—with much interest lately being in the relation between suicidal thinking and suicidal behaviour. In this Personal View we argue that, notwithstanding important and nuanced research into the nature of these phenomena, the field currently suffers from approaches to the terminology and reporting of suicidal thinking that pay insufficient regard to key features of its definition, and that these have clinical and research implications.
Although in everyday speech we talk about feeling suicidal or thinking about suicide, in clinical or academic writing the term suicidal ideation is more widely used than any other. In common usage the term refers to what has been called active suicidal ideation—that is, thoughts about undertaking the act of killing oneself (suicide) rather than to more free-floating thoughts about wishing to be dead or that life isn’t worth living. These latter cognitions, which are sometimes called passive suicidal ideation, do not relate explicitly to the act of suicide and are better considered with other aspects of negative thinking, like hopelessness and personal worthlessness, if we want to ensure a high degree of specificity in our definition of suicidal thinking—they might represent risk for suicide but they are not thoughts about suicide.Suicidal ideation as typically operationalised has various closely related definitions along the lines of “thinking about, considering or planning suicide”,2 or “thoughts of engaging in suicide-related behaviour”.3 For example, the UK’s Adult Psychiatric Morbidity Survey4 investigates a presence of suicidal ideation by asking the question “Have you ever seriously thought of taking your life, but not actually attempted to do so?”4These definitions are of course somewhat circular, their meaning dependent on how we understand terms like thought of or thinking about. The Oxford English Dictionary5 helps by unpacking the concept a bit more in its definition of to ideate: “to form the idea of; to frame, devise or construct in idea or imagination; to imagine, conceive”.5 The words imagine and imagination suggest a different way of understanding the mental state under consideration, seeming to describe mental activity with a stronger visual component such as images of real or imagined events and thoughts that are more absorbing than merely thinking. The phrase constructing an idea suggests a more extensive inner dialogue, for example coming to terms with mixed feelings of fear of or desire for death, and conceiving suggests thoughts that are of wider scope—for example, encompassing not just the fact but the specific details of the act and its imagined consequences.These different elements of suicidal ideation are likely to be marginalised or neglected altogether by the use of a single question about thinking, especially when the answer is to be given as a simple yes or no.For example, it has been recognised for some time that imagery forms a part of suicidal ideation for many people.6, 7, 8 Our experience is, however, that a question about suicidal thoughts rarely evokes a description of imagery. Further prompts are required—for example, asking whether the respondent pictures, or sees in their mind’s eye, any aspect of the act or what might happen next. Another aspect of suicidal ideation that is not often considered is the object of the thoughts. It is usually assumed that when a standard question about suicidal ideation is put, the respondent is expected to answer by describing any thoughts they have about their own suicide. However, a devised or constructed idea of suicide can be built around thoughts about the death of a third party.Some examples might illustrate these rather abstract ideas. Much attention has been given to the possibility that suicide might be induced by looking at images of self-harm on social media9, 10 or by watching representations of a fictional suicide such as that portrayed in the Netflix series 13 Reasons Why.11 If this assumption is correct, then the suicide is presumably mediated by suicidal ideation that is initiated or enhanced by imagining the self-harm or suicide of a third party. The vividness of the initial visual presentation is taken as the explanation for an assumed imaginative identification or depressive mood change, which promotes the increase in suicidal thinking. A reverse, inhibiting, effect is at play when somebody who has contemplated railway suicide says they were prevented by imagining how an attempt might play out and the effect it would have on the driver.12The main consequence of adopting and operationalising this wider definition of suicidal ideation, with all its additional complexity, is that to do so raises substantial difficulties for its use in clinical or research practice. If ideation is treated as an experience with several components that might not necessarily covary, then a single item response, whether a simple yes or no, or distributed on a severity scale, is no longer adequate. We need instead to have a workable way of investigating suicidal ideation that encompasses the wider characteristics of ideation as more or less visual, possibly self-referent or referring to others, restricted just to the act or including its wider consequences, more or less emotionally engaging, and so on.
A particular type of suicidal thinking is the suicidal intent of an act of self-harm—that is, the degree to which the individual undertaking a particular act reports that at the time their intention was that it would end their life. Another way of describing this explicit suicidal intent in this setting is to say that it refers to the specific content of suicidal ideation at the time of, and in relation to, the particular act in question.It is tempting to infer suicidal intent from the nature of an act—for example, from its potential lethality, the degree of planning, or the attempts made to avoid interruption. This approach can have value in clinical practice but the risk of error must be acknowledged—acts that are not medically dangerous can be associated with strong suicidal intent and life-threatening acts might be unplanned. It would be better to call the result of this exercise an inferred intent rather than implicit intent, thereby flagging the role of a third party in attribution.Suicidal intent cannot always be readily elicited and the US Centres for Disease Control and Prevention allow for an undetermined category: when intent can be attributed to an act, it has come to be conceptualised as either present or absent, so that the individual act can be described as non-suicidal or as having attempted suicide.13This approach, enshrined in the latest version of the American Psychiatric Association’s DSM-5, has been criticised, especially by researchers in the UK,14 but it is still adopted both in research studies15 and clinically (no doubt because clinical management decisions are very largely dichotomous in nature: admit versus do not admit, prescribe medication versus do not prescribe medication, and so on).Criticism of this dichotomising approach has been broadly along three lines. One criticism points out that non-suicidal intent has been over-identified with self-injury as if, for example, non-suicidal self-poisoning does not exist. This criticism might be true but does not speak directly to the issue of attribution of intent. A second line of criticism is that so-called non-suicidal self-injury is associated with suicidal thoughts and is indeed a risk for suicide—although perhaps less so in low-income and middle-income countries than in high-income countries.16 This notion too can be rebutted: it is not a fundamental criticism because a person at high risk of suicide who thinks often of suicide might yet undertake a non-suicidal act. In fact, people will report that a deliberately non-fatal act can be a means of averting suicide.17 More to the point is the criticism that it simply is not possible to attribute intent so neatly: intent scores on standardised measures are not bimodally distributed and expressed desire to die is often ambivalent or unclear. These ideas—that suicidal intent cannot be regarded as simply present or absent but can be thought of as present to various degrees18 and can co-exist with a desire not to die19—are long established but not captured by the practice of describing acts as straightforwardly suicidal or non-suicidal.Identification of suicidal intent is likely to be unreliable because the attribution of intent is inherently unclear and inaccurate and because of its temporal instability—that is, individual reports of intent change over very short periods of time20, 21 and as time passes after an episode. This poses a serious challenge to our current approach to intent. At the very least, it would help if reports of intent distinguished between statements made at the time or within hours of an act, and those made days or weeks later. If intent is to be expressed as dichotomous, then an important additional observation is how repeatable (reliable) the suicidal versus non-suicidal distinction is when the same question is put to the same individual on different occasions. Clinical experience tells us that stated intent changes over time as changing circumstances and emotions lead to reattribution, but we have been unable to identify a study that elicited repeated reports of stated intent (suicidal or non-suicidal) for a given act over the subsequent days, months, or years. Test–retest reliability for reports of suicidal thinking can be poor22 and repeatability is poor even for reporting of something as substantial as the act of self-harm itself,23 so we should not be confident in the reliability of one-off statements of intent.
The term suicidality covers suicidal ideation (serious thoughts about taking one’s own life), suicide plans and suicide attempts. Its use rests on an assumption that all these things represent an underlying disposition to suicide, sometimes hypothesised to lie on a continuum from thoughts to plans to non-fatal acts to suicide. There are several definitions of suicidality that are widely used in research.24 This use of the term suicidality is questionable, based upon experience of composites in other settings.25 A composite should include only items that can be shown to have similar associations and to move in similar ways, justifying their aggregation. Suicidality as currently defined does not meet this essential criterion. For example, stated non-suicidal intent can be associated with persistent suicidal ideation, and is a known risk for suicide; however, life threatening acts of self-harm can be associated with little or no suicidal intent.16 Suicidality research can produce counter-intuitive results: a 2016 review suggests that suicidality definitions that capture only thoughts and plans are as predictive of suicide as are those that incorporate thoughts, plans and actual suicide attempts.24