Method Choice and Intent
It is intuitive to think that those who attempt suicide and live were less intent on dying than those who died by suicide. While seriousness of intent plays a role in severity of attempt and choice of suicide method (means), the relationship is not a straight-forward one. Many studies (some described below) find little relationship between intent and medical severity or between intent and choice of method. Other studies, however, do find a relationship (e.g., Townsend 2001, Hamdi 1991, Harriss 2005). One reason for the mixed results is that other factors also play a role, such as the availability and acceptability of methods and attempters’ knowledge of the likely lethality of a given method. Many people who attempt suicide have inflated expectations about the lethality of common methods like poisoning and cutting.
- Thirty patients who attempted suicide with motor vehicle exhaust were interviewed (Skopek 1998). Reasons given for choosing the method included availability, painlessness, and lethality. Suicide intent scores were not high, which was inconsistent with most patients being aware that the method was highly lethal. Relationship problems were the most frequent precipitating circumstance. Most attempters regretted the attempt. Survival was due largely to failure of the method or unexpected discovery rather than to patient factors.
- Sixty patients presenting to a large urban medical center for a suicide attempt completed questionnaires measuring the seriousness of their suicidal intent and other factors (Plutchik 1988). No relationship was found between level of intent and medical seriousness of the attempt.
- Among 268 self-poisoning patients in rural Sri Lanka, 85% cited easy availability as the basis for their choice of poison (Eddelston 2006). Patients had little knowledge about the lethality of the poison they chose. There was no evidence that attempters who used highly toxic poisons were more serious or deliberative in their attempt than those using less toxic poisons.
- Patients’ expectation of the lethality of their attempt (as measured by the Beck Suicidal Intent Scale item 11) was not associated with observed medical severity in a sample of 173 attempters treated in an urban emergency department (Brown 2004). Only 38% of the patients were accurate in their expectations regarding severity; 32% were inaccurate, and 29% did not know whether what they did was likely to be lethal.
- A study of 33 people (mostly young men) who attempted suicide with a firearm and lived found that all used firearms obtained in their homes (Peterson 1985). When asked why a firearm was used, the answer given most often was, “Availability.”
- A Houston study compared nearly lethal suicide attempts with less-lethal attempts and found that expectation of dying, planning, impulsivity, and taking precautions against discovery were not associated with the medical severity of the attempt (Swahn 2001).
Intent is a complex matter and falls along a continuum. While some attempters are probably at the low end of the spectrum with very little intent to die, and others are at the high end, many fall into an ambivalent middle ground. Still others have high intent but only during very brief episodes. It is these latter two groups for whom reducing easy access to highly lethal methods of suicide is likely to be most effective in saving lives.
More studies – (Intent, Lethality and Method Choice in Suicide Attempts)
Factors Influencing Lethality
A number of factors influence the lethality of a given method.
- Inherent deadliness. For example, car exhaust with a high carbon monoxide level will be more deadly than car exhaust with a low carbon monoxide level.
- Ease of use. A method that requires technical knowledge is less likely to be used to lethal effect than one that does not unless the person has that technical knowledge.
- Immediate access. Given the brief duration of many suicidal crises, a lethal dose of pills in the medicine cabinet poses a greater danger than a prescription that must be hoarded over months to accumulate a lethal dose. Similarly, a gun in the closet poses a greater risk than a very high bridge five miles away, even if both methods have equal inherent deadliness if used. The longer it takes to get to the bridge, the greater the chance the suicidal crisis will subside.
- Inability to abort mid-attempt. More people start an attempt and abort it than carry it through. Nearly all suicide methods offer a window of opportunity for rescue or change of heart. Guns and jumps do not.
- Acceptability to the attempter. Although fire, for example, is universally accessible, it is rarely used in the U.S. for suicide because it is not acceptable to people.
Firearms kept at home rate high on all of these dimensions. This is why gun owners have higher suicide rates than non-gun owners, even though they’re not more likely, on average, to have a mental health problem or to seriously consider or attempt suicide.
Eddleston M, Karunaratne A, Weerakoon M, Kumarasinghe S, Rajapakshe M, Sheriff MH, Buckley NA, Gunnell D.Choice of poison for intentional self-poisoning in rural Sri Lanka.Clin Toxicol (Phila). 2006;44(3):283-6.
Hamdi E, Amin Y, and Mattar T. Clinical correlates of intent in attempted suicide. Acta Psychiatr Scand. 1991;83(5):406-11.
Harriss L, Hawton K, Zahl D. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Brit J Psych. 2005;186:60-66.
Peterson L, Peterson M, O’Shanick G, and Swann A. Self-inflicted gunshot wounds: Lethality of method versus intent. American Journal of Psychiatry. 1985;142:228-231.
Plutchik R, van Praag HM, Picard S, Conte HR, and Korn M. Is there a relation between the seriousness of suicidal intent and the lethality of the suicide attempt? Psychiatry Resesarch. 1988; 27:71-79.
Swahn MH and Potter LB. Factors associated with the medical severity of suicide attempts in youths and young adults. Suicide and Life-Threatening Behavior. 2001;32:21-29.