Before the attempt: How people think and plan in suicide crises

Cognitive processes preceding suicidal attempts (SA) remain poorly understood, particularly in distinguishing those who act on suicidal thoughts from those who do not. This study compared proximal contemplation and planning processes during suicidal crises that ended in suicide attempts (SA+, n = 417) versus those that involved suicide planning but did not end up in an attempt (SP+, n = 191). Participants reported on the degree and timing of reasons for dying (RFD), reasons for living (RFL), mulling, and planning features. In both groups, ideation and mulling typically began 3-12 h before the episode's endpoint, and all planning features typically began 1-3 h prior. Planning preceded 66 % of attempts when measured with a single-item and 89 % when defined by considering any one of the three components (i.e., method, location, or time). Mulling was reported in 72 % of SA+ episodes and 84 % of SP+ episodes. Machine learning models identified top contemplation features associated with classification in the SA+ group: (1) heightened focus on RFD, (2) absence of mulling, (3) greater consideration of beliefs that encourage suicide, (4) lower consideration of personal responsibilities as RFL, and (5) shorter mulling duration. For planning features, SA+ classification was associated with (1) earlier method decision, (2) later location decision, (3) later location consideration, and (4) lower plan specificity. By capturing the content, intensity, and duration of contemplation and planning during crises, these findings reveal how specific cognitive patterns may inform behavioral risk and highlight the value of precise measurement in understanding suicide decision-making.