Pathway from Suicidal Ideation to Attempt Among Adults with Psychosis

Background and Purpose: Although individuals with schizophrenia spectrum disorders (SSDs) face substantially elevated suicide risk, there is limited empirical understanding of how suicidal ideation transitions towards suicide attempt behavior within this population. This study sought to examine the lived experiences of suicide attempt among adults with SSDs, with the goal of identifying key steps in the progression from ideation to action, as well as the timing and sequence of these processes.

Methods: A mixed-methods approach was employed with quantitative and qualitative data collection from adults receiving care in a United States community mental health (CMH) setting. Participants (n = 19) were diagnosed with an SSD, had a lifetime history of suicide attempt, and reported suicidal ideation within the past six months. The Pathway to Suicidal Action Interview (PSAI) was administered to capture detailed accounts of participants’ most recent suicide attempt, including cognitive, emotional, and behavioral factors preceding the event. Quantitative analyses characterized the timing and frequency of pathway components, while qualitative responses were examined using a hybrid analytic strategy that combined deductive and inductive coding.

Results: The transition from a decision to attempt suicide to the initiation of action was often rapid. The most frequently reported timeframe between decision and action was approximately 30 minutes, although many participants described shifts occurring within minutes or seconds. After the first behavioral step, progression toward the attempt action was typically immediate, with a modal timeframe of approximately 30 seconds. The majority of participants did not report engaging in preparatory behaviors (68%) or extended periods of contemplation (53%). Most participants endorsed depressive symptoms (89%) during the time of their attempt, and a substantial proportion reported active psychosis symptoms (63%). Nearly half (47%) described experiencing auditory hallucinations involving commands or suggestions related to death or self-harm. Qualitative findings highlighted several recurring themes, including impulsivity, access to means, psychosis-related influences, ambivalence about dying, contextual triggers (e.g., interpersonal stressors), characteristics of the attempt setting, movement or travel preceding the attempt, and the role of other people during the event.

Conclusions and Implications: These findings underscore both the heterogeneity of suicide attempt pathways and the rapid progression from ideation to action among adults with SSDs. The limited presence of preparatory behaviors and short timeframes observed suggest that prevention strategies focused solely on long-term planning may be insufficient. Instead, results point to the need for interventions that prioritize immediate risk reduction, including limiting access to lethal means, addressing acute distress, and targeting specific psychosis symptoms that can elevate suicide risk. Future research with larger and more diverse samples is needed to extend these findings and inform real-time suicide prevention efforts.