This is an incredibly important article for all healthcare professionals.
Suicide (and suicidal thoughts/behaviors) are among the most important issues healthcare providers will need to communicate about. However, the terms we use to describe these behaviors can be confusing, at a time when we must get it right.
I found Dr. Rajnish Mango’s writing on how to define and distinguish between the varying types of suicidal behavior extremely helpful for physicians and health care providers of all specialties and have slightly adapted his comments here.
Why Is This So Important?
Suicide prevention is possible and studies show that health care providers can have a much greater influence on preventing suicide than what is typically understood or assumed.
In fact, according to a study published in the American Journal of Psychiatry, almost half (45%) of individuals who die by suicide have visited a primary care provider in the month prior to their death, and 20% have had contact with a mental health service provider. Additionally, 10% of people who die by suicide have been in the emergency care department in the 2 months prior to their death.
NOTE: Here is another article I wrote on how to screen for suicide risks. I recommend reading it as well.
Type Of Suicidal Behaviors
Many different types of behaviors are sometimes referred to as suicide attempts, and that lack of agreement about what to call different types of suicidal behaviors can be a problem clinically.
However, the Columbia Suicide History Form (Oquendo et al., 2013) provides a definition of the differences between an Actual Attempt, an Interrupted Event, an Aborted Attempt, and Preparatory Acts. These definitions are also used in the Columbia – Suicide Severity Rating Scale (C-SSRS) which is now routinely used in antidepressant clinical trials.
A) Actual Attempt
An Actual Attempt is defined as a potentially self-injurious act committed with at least some intent to die as a result of act.
This definition can lead to many gray areas and uncertainty, so several clarifications have also been provided.
To be called an Actual Attempt, the person does not have to be explicit or 100% intent on killing themselves. As long as there is at least a partial thought that the act might end in death means that the act is considered an Actual Attempt.
Additionally, it is NOT a requirement that injury or harm actually occur. The C-SSRS gives the example that if a person puts a gun in his or her mouth and pulls the trigger, but the gun is broken and no injury occurs, it is still considered an Actual Attempt.
What’s more, even if the person denies that they intended to die as a result of the act, the intent to die can be inferred by the act itself. For example, if a person engages in a behavior that could obviously lead to death and there is no other possible reasonable alternative explanation, a provider can assume there was suicidal intent and can be classified as an Actual attempt.
Similarly, if the patient claims he or she was not trying to kill themselves, but admits that they realized they could die, it can be concluded that there was suicidal intent and the act can be classified as an Actual attempt.
B) Interrupted Attempt
An Interrupted Attempt is when a person intends to start a suicidal behavior, but then someone or something stops the person from starting the act.
It’s important to note, however, that if the person starts the suicidal act (takes a single pill in an attempt to overdose), but is then stopped by someone, it would be considered an ACTUAL Attempt.
The key to an INTERRUPTED Attempt is that the person is prevented from starting the act in the first place.
An example of an Interrupted Attempt would be if a person opens a bottle of pills and is ready to take them in order to kill themselves when someone comes in to the room and prevents them. Another example would be a person who is standing on the ledge of a roof with the intention to jump but then gets pulled off the edge by someone else.
It’s crucial to identify Interrupted Attempts because many people have been known to take precautions not to be interrupted in subsequent attempts.
C) Aborted Attempt
An Aborted Attempt is when a person starts a suicidal behavior, but stops himself or herself before starting any potentially lethal behavior.
To clarify, if a person has suicidal ideation with a specific plan and intent, but does not carry out the plan, this should not be called an Aborted Attempt. It would only be considered an Aborted Attempt if the person took some step to start a suicidal act. For example, if someone picks up a gun and holds it to their head, but before pulling the trigger changes their mind, it would be considered an Aborted Attempt.
The main difference between an Interrupted Attempt and an Aborted Attempt is WHO stops the act. Is it the suicidal person? That’s an Aborted Attempt. Is it another person or external circumstance? That’s an Interrupted Attempt.
D) Preparatory Acts or Behaviors
This is any act that is directly in preparation for making a suicide attempt. Examples would include buying pills, acquiring a gun, writing a suicide note, giving one’s belongings away, etc.
The C-SSRS suggests the following question to ask about Preparatory Acts or Behavior:
Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?
All health professionals should understand these terms. Additionally, all health professionals have the access and opportunity to connect one-on-one with patients and for a patient experiencing suicidal ideation or behavior, a meeting with a healthcare provider can be the safe setting needed to help them open up and get the needed help before it’s too late.
This unique opportunity for assessment and prevention could be life-saving, so it is clearly essential that all providers know how to effectively screen for suicide risk. As a provider, you cannot predict death by suicide, but you most certainly can learn to identify people who are at increased risk, start taking precautions, and help them get effective treatment.
NOTE: this is a good article on knowing how to open a conversation about suicide with patients.
Beyond that, it’s imperative that you understand the importance of referring the patient to inpatient care if they are actively suicidal or refer them immediately to a qualified psychiatrist if they are not actively suicidal.
Suicide screening and prevention is an often overlooked role by many health care providers. However, I urge you to be aware of how valuable and potentially life-saving this role can be.
For more in-depth information please contact our office at email@example.com or call 917-609-4990 to discuss additional options.
Amanda Itzkoff, MD