Most people with suicidal ideas do not act on them. Our understanding of the transition from suicidal ideas to action is very much limited. David Klonsky & Alexis May from the British Columbia University explores this subject in this months editorial.
A large population-based study from Netherlands (ten Have et al 2009) reported that only 7.4% of those with baseline suicidal ideation reported a suicide attempt over the subsequent 2 years. Differences between ideators and attempters is an area of key knowledge that is lacking. Kesler et al , after analysing the National Comorbidity Survey (Kessler et al., 1999) reported that “all significant risk factors … were more strongly related to ideation than to progression from ideation to a plan or an attempt”. Odds Ratios were quite high for distinguishing suicide ideators from those who have never been suicidal i.e. individuals with such conditions as depression were more likely to have suicidal ideas. In contrast, the odds ratios for distinguishing attempters from ideators were very low. Other studies have also confirmed this pattern.(e.g.: Borges, & Ono, 2012, Nock et al., 2013).
Hopelessness has long been emphasized as an important suicide risk factor, however this also fail to differentiate between ideators and attempters (Acosta et al., 2012 etc).
Would impulsivity explain the transition? It has been mentioned that individuals high on impulsivity are “more likely to act on suicidal feelings” and as “a more significant indicator of suicide attempt than the presence of a specific suicide plan”. Empirical findings do not support this notion. In a large military sample, impulsivity was equivalent between attempters and ideators (Klonsky & May, 2010).
Theoretical context of this differentiation come from Joiner’s interpersonal theory of suicide which states that perceived burdensomeness and low belongingness combine to create suicidal desire, whereas the capability to act on desire is acquired over time through exposure to painful and provocative events (Van Orden et al., 2010) .Rory O’Connor’s motivational– volitional theory of suicidal behaviour also stress on capability with focus on dispositional pain sensitivity and physical access to lethal means as additional factors.
Authors suggest that ‘ideation- to-action’ framework should be used in studying risk factors and processes in suicide. They stress the need to better understand progression from ideation to attempts.
Summary of the article:
Klonsky ED, May AM. Suicide Life Threat Behav. 2014 Feb;44(1):1-5