From Suicidal Ideation To Suicidal Actions:A Study On The Differences Regarding Suicide-Related Motivational Process

In the field of suicide research,among many other challenges,the most important one faced by scholars is the ability to be sensitive and accurate on prediction.This prediction is not only about who will or will not develop suicidal thoughts,but also when they will put the thoughts into action.One reason for the slow progress in suicide prevention research is lacking of sufficient understanding about the transition from suicidal thoughts to suicidal actions.In fact,most people who think about suicide do not take further action.A relatively high rate of suicidal ideation along with a low rate of suicide attempts suggests that it is of importance to understand the differences between suicide attempters and suicide ideators,and to identify under what circumstances,suicide ideators have the highest risk to commit suicide.By understanding this will not only promote the development of the suicide theory,but also greatly improve the accuracy of crisis evaluation and intervention.In the literature review,we reviewed the development of suicide research and found that there is a large gap in understanding how suicidal ideation transform into suicidal actions.The previous suicide studies cannot distinguish between suicidal ideators and suicide attempters as the widely recognized suicide risk factors literally are factors for suicidal ideation.These factors can screen for suicidal ideators,but cannot explain the change from ideation to actions(Klonsky&May,2014).In this context,recently,researchers proposed an ideation-to-action framework.This theoretical framework considers the development of suicidal ideation and the transformation from ideation to suicidal action as two different processes with different interpretations and predictors.The framework has opened a new chapter for the suicide research.In this framework,researchers have proposed several important ideation-to-action models,re-examined a large number of existed risk factors,and found that some of the factors can be used to distinguish between suicidal ideation and suicidal action.However,there are still some issues that are not clear:(1)Is the change in suicidal ideation to suicidal action due to a third variable or the difference in suicidal ideation?(2)A lot of researches focused on the development of distant risk factors or suicidal thoughts,but not much studies are related to individual cognitive processes after having suicidal idea.Moreover,these studies paid more attention on the verbal thoughts,while ignoring mental imagery and emotional aspects in suicidal ideation.(3)There is insufficient understanding of the role of suicidal intent in the ideation-to-action process.Suicidal actions develop from suicidal intent.The current ideation-to-action framework divides the development of suicide process into two stages:the generation of suicidal ideation,and the transformation from suicidal ideation into suicidal action.The current framework,however,ignores the step from suicidal ideation to suicidal intent.This is a key step as individuals show difference at this stage.And this stage can be treated as the 'first threshold' for distinguishing suicidal ideators from suicidal actors.Based on these issues,this study starts from the suicidal ideation of suicidal ideators and suicidal actors.The aim is to find the key differences in the content or composition of suicidal ideation among suicidal ideators and suicide actors,and then to explore how the proximal motivation variables affect the transformation from suicidal ideation to suicidal action.Specifically,the five studies are as follows:Study 1 aims to explore the differences in the content or composition of suicidal ideation among college students with suicidal ideation or suicidal actions.The subjects were from a psychiatric department in a general hospital in Wuhan.13 students who had suicidal ideation along with another 13 students who had suicidal actions in the past year were selected.Using semi-structure interviews,we collected the proximal cognitive emotional states in the process from generating suicide thoughts to taking or abandon suicide action.Then,five investigators conducted an in-depth analysis for the interview materials using Consensus Qualitative Research(CQR).The qualitative analysis found that,from the occurrence of suicide trigger events(or non-existence)to the individual's final behavior(take or abandon suicide),the factors affecting their final decisions can be divided into five aspects:formation of suicide ideation(I want to die),evaluations of suicide outcomes(whether I should commit suicide or not),expectations on suicide process(how to commit suicide),suicide/death related beliefs and attitude,and suicidal ideation adjustment.These five aspects together can describe the development of suicide behavior from the perspective of proximal factors.By comparing the differences between suicidal ideators and suicide actors in these five aspects,it is found that the biggest differences are from evaluations of suicide outcomes and expectations on suicide process.The former mainly affects the formation of the suicide intent,while the latter directly affects the suicide action.Therefore,study 2 to study 5 further studied the relationship between these influential factors and suicide intent and suicidal actions,and also explored a series of mechanisms regarding the process of suicidal ideation?suicidal intent?suicide action.Study 2 aims to develop a prefactual thinking questionnaire regarding suicide outcomes.For subsequent research,this questionnaire was used to measure the prefactual thinking of suicidal outcomes among college students who have suicidal thoughts.A questionnaire survey was conducted in 3,744 college students from six regions across the country,and 607 of them with suicidal ideation were screened out as research subjects.The results show that the prefactual thinking questionnaire has good reliability and validity when used in college students.Study 3 aims to explore the impact of prefactual thinking about suicide outcomes on suicide intent and its mechanisms.By doing this,we try to understand the formation of suicide intent which is an important link for the development process from suicidal ideation to suicidal action.In this study,we used a questionnaire survey.510 college students with suicidal ideation were selected from six regions of the country.The results of the sub-study 1 show that,both the negative reinforcement of suicide and the positive reinforcement of suicide have a positive predictive effect on suicide intent.And this effect is fully mediated by the evaluative rationality of suicide.In addition,the negative outcomes and the loss of suicide have negative effect on suicide intent.Specifically,the influence of negative outcomes is completely mediated by the rationality of suicide,while the influence of the loss of suicide is partly mediated by the rationality of suicide.From the perspective of 'person-centered',sub-study 2 aims to further explore the potential patterns of prefactuals regarding suicide outcomes and the impacts of different kinds of prefactual thinking on suicide intent.The results show that:(1)By using a latent profile analysis,students who have suicidal ideation usually have five latent types of prefactual thinking:'low-conflict','moderate-conflict','full of worries',‘high-conflict',and'determined about death'.(2)These five latent types of prefactuals have different effects on suicide intent.Among them,the rationality of suicide has the strongest mediating effect on suicide intent for the type of‘determined about death',followed by 'moderate-conflict' type,and 'full of worries'type and 'low-conflict' type.Study 4 aims to explore the impact of mental imagery about suicide process on suicide action and its mechanisms.On the basis of study 1,this study further explores the differences in suicidal-related imaginary between suicidal ideators and suicidal actors(sub-study 1),as well as how the individual's imagery affect the suicidal action,and by which mechanism this effect works(sub-study 2).This study is a questionnaire survey.A total of 143 psychiatric inpatients were collected from a general hospital psychiatric department and two psychiatric hospitals in Hubei.All of the participants are college students and had suicidal ideation or actions in the past year.The results show that:(1)There are differences in suicidal imagery frequency,content,and related characteristics between suicidal ideators and suicidal actors.Logistic regression analysis shows that the mental imagery about suicide process and the related comfort feelings are significantly related to suicide actions;(2)The mental imagery about suicide process can have an effect on the suicidal action through the mediating role of positive associated affect.And this mediation is moderated by the sense of realness and control during the suicidal simulation.With the high level of realness and low level of control,the process simulation has the strongest effect on suicidal action through comfort feelings;(3)The mental imagery about suicide process can also increase individual's self-efficacy on suicide,then affect the suicide planning,and then promote suicidal action.Study 5 aims to investigate the role of suicide intent,suicidal process simulation,and their interaction on distinguish between suicidal ideators and suicidal actors.After exploring the development process from suicide ideation to suicide intent in study 3 and the impact of suicidal process simulation on suicidal action in study 4,this study intends to integrate these two key variables in the ideation-to-action framework and investigate the distinguishing effect of the interaction of suicide intent and suicidal process simulation on three types of suicide behaviors.The participants are the same as in study 4.The results show that,for the current ideators and the past attempters,the main factor that distinguishes them is the suicide intent;for the past attempters and recent attempters,the suicidal process simulation can distinguish them;for the current ideators and recent attempters,the suicide intent,the suicidal process simulation,and their interaction can all distinguish them.In detail,the relationship between the suicide intent and suicidal actions is significant only in the middle to high level of suicidal process simulation.That is,the stronger the suicide intent and the higher the suicidal process simulation,the more likely to actually commit suicidal behavior.Based on the above findings,in conclusion,suicidal ideators and suicidal actors differ in the content or composition of suicide ideation.After a suicidal idea comes up,individual's prefactual thinking about suicide outcomes will affect the formation of suicide intent.In addition,individual's suicidal process simulation directly affects the likelihood of suicide actions,and also moderating the development processes from suicide intent to suicidal actions.This study provides new findings for the development process from suicidal ideation to suicidal actions.In the future,more in-depth and careful researches will be needed within the ideation-to-action framework.It is also highly worth to develop a powerful scale to identify and predict suicide actions and develop targeted intervention strategies.