So many different types of behaviors are sometimes referred to as suicide attempts. The lack of clarity and agreement about what to call different types of suicidal behaviors is a problem clinically and in clinical research. But there is a difference between an Actual Attempt, an Interrupted Event, an Aborted Attempt, and Preparatory Acts/Behavior.
The Columbia Suicide History Form (Oquendo et al., 2013) did us a valuable service by providing definitions of different behaviors. These definitions are also used in the Columbia – Suicide Severity Rating Scale (C-SSRS) which is now routinely used in antidepressant clinical trials.
An Actual Attempt is defined as a potentially self-injurious act committed with at least some intent to die (which does not have to be explicit) as a result of act.
I might as well say upfront that I don’t like this term–it implies that if a person starts a suicidal behavior but is, thankfully, stopped by someone (“Interrupted Attempt,” see below), that this was not an “actual” attempt. From the viewpoint of the serious clinical implications of the behavior, an Interrupted Attempt may have the same significance as an “Actual” attempt. But since Actual Attempt is the term used by the sources I am using, so I will follow it here.
In real-life situations, the mental state of persons who have suicidal behavior and the circumstances in which the suicidal behavior occurs mean that there are many gray situations. To avoid uncertainty, several clarifications have been provided regarding situations in which we would call the behavior an Actual Attempt.
1. To be called an Actual Attempt, the person there does not need to be a 100% intent to kill oneself. Even a partial thought that this act will or may kill oneself means that this act was an Actual Attempt.
Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt.
2. To be called an Actual Attempt, it is not a requirement that injury or harm 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, this is still considered an Actual Attempt.
3. After an Actual Attempt, even if the person denies that he or she wanted to die or intended to die as a result of the behavior, the intent to die can be inferred from the circumstances. For example, if the person does a behavior that obviously could be very lethal (e.g., jumping from a considerable height) and for which no reasonable alternative explanation is possible, the clinician can assume that there was suicidal intent even if the person denies that it was a suicide attempt.
4. Similarly, if the person says that he was not trying to kill himself, but admits that he did think that he could die, we can conclude that there was suicidal intent.
If a person intends to start a suicidal behavior, but someone or something stops the person from STARTING the act, this should be called an Interrupted Attempt. What this means is that if someone or something had not stopped the person, an Actual Attempt would have occurred.
Note: If the person starts the suicidal act (e.g., takes a single pill in an attempt to overdose), and is then stopped by someone, this should be called an Actual Attempt.
Here are some examples of what would constitute an Interrupted Attempt:
– A person opens a bottle of pills and is ready to take them in order to kill herself, but someone comes into the room.
– A person is standing at the edge of the roof with the intention to jump, but someone grabs him and prevents him from jumping.
The C-SSRS suggests the following question to ask about Interrupted Attempts:
Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything?
Some persons who have an Interrupted Attempt are known to take precautions in a subsequent suicide attempt to not be interrupted and die by suicide in that subsequent event.
If a person starts a suicidal behavior, but stops himself or herself before starting to carry out any potentially lethal behavior, this should be called an Aborted Attempt.
– If 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 unless the person actually took some step that started the suicidal act. For example, if the person opens a bottle of pills and takes some pills out into his or her hand, but immediately before taking the pills, changes his or her mind, this would be called an Aborted Attempt.
– The difference between an Interrupted Attempt and an Aborted Attempt is that in an Interrupted Attempt, it is another person or external circumstances that stop the person from continuing the suicide attempt.
The C-SSRS suggests the following question to ask about any Aborted Attempts:
Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything?
Preparatory Acts or Behavior
These are any acts that are directly in preparation for making a suicide attempt. Acts or preparation towards imminently making a suicide attempt. Examples: buying pills, writing a suicide note, giving one’s belongings away.
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)?