Do you have thoughts about harming or killing yourself?” — a question on any standard pre-therapy questionnaire. A simple yes/no, binary question. An exceptionally complex and personal question. Did I have thoughts about killing myself? Didn’t we all? I thought that everyone occasionally thought about dying. Perhaps not to the extent they meant, but to a normal extent. How much is a ‘normal’ amount to think about suicide?

There was a point where suicide would present itself as a solution to all my problems on an hourly basis. And yet, here I was, years post my darkest point, where the thought would pop up now and again as a solution to any and all problems. It’s difficult to articulate, let alone categorise suicidal thoughts. Should it be placed in between other intrusive thoughts, next to the strange pull you feel standing on a high ledge, or the urge to kick a small animal? Or is it indicative of a larger trend of depressive symptoms that you need to tell your support network about immediately?

The great bible of mental illnesses (ICD-11) defines suicidal ideation as thoughts, ideas, or desires for suicide, ranging from simply wishing to be dead to making elaborate plans. It’s a vague definition, perhaps purposefully so, as there aren’t clear or reliable characteristics for suicide ideation. However, it is a constant presence in many diagnostic criteria to determine if an individual is at risk of committing suicide.

Suicide ideation can be categorised as either active or passive. Active ideation involves a conscious desire to self-harm with death as the intended outcome. Passive ideation is subtler, reflecting an indifference to accidental death and a resignation to mortality.

As with everything regarding suicide, it's never quite clear how much of a risk any of these thoughts pose. You could have a passing wish to sleep forever and never wake up or be intensely preoccupied with the idea, even forming detailed plans. These thoughts ebb and flow, sometimes fluctuating multiple times a day (Harmer et al, 2023), and frustratingly, it is only in retrospect that one can see clearly if they were a warning sign, or simply the brain’s way of coping with stress.

Studies attempting to show what might trigger suicidal ideation are equally vague. Psychiatric disorders, physical illness, family history of mental illness, previous suicidal attempts, unemployment, poor social support, and psychotic symptoms are all listed as likely reasons people might ideate. A study found that individuals with a family history of mental illness are three times more likely to experience suicidal ideation. Those with previous suicide attempts are 27 times more likely to have suicidal thoughts compared to those without. Additionally, individuals with major depressive disorders are 11 times more likely to experience suicidal ideation than those with bipolar disorders. (Tsegay, Damte, & Kiros, 2020)

It’s impossible to discuss suicidal ideation without also discussing suicidal behaviors or outcomes. But perhaps counter-intuitively, the two are not necessarily always linked. Fortunately, not all suicide ideators will commit suicide. In 2021, The Centres for Disease Control estimated that for every 1 suicide attempt in the U.S., 2 adults exhibited active suicidal ideation and had plans, and seven adults were ideating passively (Snowdon & Choi, 2020). However, these figures are highly subjective and often misclassified as accidental deaths.

It was originally thought that active suicidal ideation posed a greater risk than passive. However, it has now been demonstrated that not even that much is clear. Large population-based studies have shown no significant difference in the odds of suicide attempts between those with passive and active ideation (Harmer, et al, 2020). More generally, either type of ideation is a weak predictor of increased lifetime risk; it does not predict imminent risk. But on reflection, does anything? “As there is no “typical” suicide victim, there are no “typical” suicidal thoughts and actions.” (Harmer et al, 2023). Suicide transcends all demographic, psychiatric, and medical groups, leaving no one untouched.

Despite that suicide ideation cannot conclusively be labeled as a definite risk factor, health professionals include suicidal ideation in suicide risk assessments, using it as a symptom of most mental disorders. As with all tragedies, the warning signs are only clear if the worst happens. Suicide is tricky. Once the idea first pops into your head as a solution to a problem, it sticks around like a latent virus, waiting to take over when you’re at your weakest.

The desire for suicide without substantial action often happens with prolonged mental health issues and early suicidality. When you’re young, your neural pathways rearrange, and these changes influence your coping mechanisms. Suicidal ideation can become an ingrained coping mechanism, a sort of 'at least suicide is always there for me.' Your brain is like a muscle; it remembers, learns, and adapts. These thoughts are just a reflex. It doesn't mean you are weak or not in recovery. It's more of a warning sign now for stressors, difficult emotions, or unmet needs you may have overlooked or failed to validate.

In recovery, we must recognise that these thoughts can and do pop up. They might just be neural pathways firing, much like a car's alert lights. When the petrol light comes on, we may need to adjust our course, but we shouldn't stop driving entirely. We need to open up the discussion around suicidal ideation to remove the stigma, allowing people to speak more freely about this 'awkward' part of recovery. Moreover, we should move away from the binary aspect of suicidal ideation and focus on evaluating the intensity and danger of these thoughts. By doing so, we can better understand and manage them, ensuring we address our needs without halting our progress.