BJPsych Open (2021) 0, e0, 1–6. doi: 10.1192/bjo.2021.15 1 2 3 4 Patterns and motivations for method choices in 5 6 suicidal thoughts and behaviour: qualitative 7 8 content analysis of a large online survey 9 10 Lisa Marzano, Dafni Katsampa, Jay-Marie Mackenzie, Ian Kruger, Nazli El-Gharbawi, 11 Denika Ffolkes-St-Helene, Hafswa Mohiddin and Bob Fields 12 13 Background be lethal, ‘easy’, quick, accessible and/or painless. Methods 14 Choice of suicide method can strongly influence the outcome of used in suicide attempts were, above all, described as having 15 suicidal behaviour, and is an important aspect of the process and been accessible at the time, and were more commonly said to 16 planning involved in a suicide attempt. Yet, the reasons why have been chosen impulsively. Key deterrents against the use of 17 individuals consider, choose or discard particular methods are specific methods were the presence of and impact on other 18 not well understood. people, especially loved ones, and fears of injury and survival. 19 Conclusions 20 Aims Exploration of method choices can offer novel insights into the 21 This is the first study to explore method choices among people transition from suicidal ideation to behaviour. Results under- 22 with a history of suicidal behaviour and individuals who have experienced, but not enacted, suicidal thoughts. score the need for preventative measures to restrict access to 23 means and delay impulsive behaviour. 24 Method 25 Via an online survey, we gathered open-ended data about choice Keywords 26 of methods in relation to suicidal thoughts and behaviours, Attempted suicide; suicide; self-harm; suicidal ideation; suicide 27 including reasons for and against specific means of harm. method. 28 29 Results Copyright and usage 30 A total of 712 respondents had attempted suicide, and a further © The Author(s), 2021. Published by Cambridge University Press 31 686 experienced suicidal thoughts (but not acted on them). Self- on behalf of the Royal College of Psychiatrists. This is an Open poisoning was the most commonly contemplated and used Access article, distributed under the terms of the Creative 32 method of suicide, but most respondents had considered mul- Commons Attribution licence (http://creativecommons.org/ 33 tiple methods. Method choices when contemplating suicide licenses/by/4.0/), which permits unrestricted re-use, distribu- 34 included a broader range of means than those used in actual tion, and reproduction in any medium, provided the original work 35 attempts, and more unusual methods, particularly if perceived to is properly cited. 36 37 38 Background their significance in relation to a relatively narrow range of 39 5 40 Suicide is a leading cause of death worldwide.1 In England, the 2014 methods and with generally small study samples. Furthermore, 41 Adult Psychiatric Morbidity Survey found that a fifth of adults earlier literature has tended to focus on fatal and non-fatal suicidal 42 (20.6%) reported thoughts of taking their own life at some point, behaviour, overlooking its immediate, and generally less under- 43 and one person in 15 (6.7%) has made a suicide attempt.2 Choice stood, precursor: suicidal ideation. Understanding the psychological 44 of method is one of the most important determinants of whether processes preceding a suicide attempt is crucial for the potential to 45 suicidal behaviour is fatal, and a key aspect of the process and plan- intervene, as is knowing what prevents the majority of individuals in 46 ning involved in a suicide attempt. Indeed, earlier studies have distress from acting on thoughts of suicide, at a particular moment 47 shown that gathering information and access to means of suicide and/or over time. 48 are known indicators of high suicidal intent and risk.3,4 Yet, previ- The stability, or otherwise, of method choices also warrants 49 ous literature has mostly focused on prevalence of methods, and further attention. A recent systematic review found that a third of 50 associations with gender, age and mental disorder.5 How or why individuals (33.3%) switch methods between successive episodes individuals consider, choose or discard particular methods are not of self-harm, and almost half (42.11%) between an episode of self- 51 13 52 well understood. harm and suicide. Based on prevalence of methods, there Epidemiological studies have shown that different methods, and appears to be no discernible or predictable pattern to such means 53 9,13 54 combinations of methods, vary not only in relation to lethality, but switching. Exploration of meanings, motivations and mechan- 55 also in the extent to which they predict subsequent suicidal behav- isms may, however, offer valuable new insights. For example, a – 56 iour and ‘method switching’.6 10 Their wider impact can also vary, study in Austria showed that, despite method switching between 57 not least by virtue of the exposure and potential clustering/’conta- episodes of self-harm being common, choice of means in the time gion’ effects associated with more public, unusual and ‘newsworthy’ immediately preceding a suicide attempt is often stable, and 58 8 59 methods.11 Indeed, avoiding ‘excessive detail of the method […]to focused on a single method. 60 prevent simulative acts’ remains to date the only official regulation 61 for the reporting of suicide in the UK.12 62 This clearly points to the importance of better understanding Aims 63 the cultural and cognitive availability of different methods of The present study aimed to investigate, for the first time, first- 64 suicide. Previous studies in this emerging field have identified person accounts of the factors deterring and prompting consider- 65 these as key drivers in people’s method choices, but have explored ation and/or use of specific methods of suicide among people 1 Marzano et al 66 with a history of suicidal behaviour and those who have experi- the beginning and the end of the survey. All participants gave 67 enced, but not enacted, suicidal thoughts. Dominant models of sui- informed consent to participate in this study, and all research mate- 68 cidal behaviour point to this as an important distinction, with rials and procedures were reviewed and approved by the Psychology 69 potential for novel insights into the transition from suicidal ideation Department Research Ethics Committee at Middlesex University 70 to behaviour.14,15 Given the disproportionate risk of suicide in men (reference: ST019-2015). 71 in the UK,16 gender differences in method choices were also 72 explored, in relation to both suicidal ideation and behaviour. Statistical analysis 73 Open-ended survey responses were coded through a multi-stepped 74 approach. Suicide methods were classified using the intentional self- 75 Method harm (X60–X84) codes of ICD-10.19 Reasons for engaging in 76 specific methods were analysed inductively for content,20 and 77 Online survey an additional coding category was created to capture deterring 78 Data were gathered as part of a wider study of method and location factors, where reported. Three coders (D.F.St-H., H.M., N.E.-G.) 79 choices in relation to suicidal thoughts and attempts in the UK coded 10% of the data, with substantial interrater reliability 80 (QUEST, Qualitative Understanding of Experiencing Suicidal (Kraemer’s kappa 0.774) (see Supplementary Appendix for a full 81 17,18 Thoughts ). A national online survey inviting people to share description of the coding protocol and details of interrater reliability 82 their experiences of suicidality was advertised through suicide pre- in relation to individual code categories). 83 vention organisations such as Samaritans UK, online forums, social Survey data are presented as frequencies or percentages, as 84 media and special interest groups. Study posters and leaflets were appropriate. Variations in method choices were analysed using 85 also placed on university bulletin boards, at local branch offices of chi-square tests (for categorical variables) and t- and Mann– 86 relevant charities, in the National Suicide Prevention Alliance news- Whitney U-tests (for continuous variables). All statistical analyses 87 letter and were mailed out to supporters of the charity Campaign were performed at a 5% level of significance. 88 Against Living Miserably (CALM). 89 The 16-item anonymous survey asked participants if they had 90 ever experienced suicidal thoughts and, if applicable, to describe Results 91 in an open-text format whether this involved a specific method or 92 methods, and why. Those who reported prior suicidal behaviour We analysed the responses of 1398 people (Table 1). Of these, 68.5% 93 were then asked the same question in relation to their suicide identified as females, 29.5% as males, and 2.0% as transgender/ 94 attempt/s. All questions were optional, and no word limit, prompt- gender fluid. Participants had a median age of 32 years (range 16– 95 ing or structure were imposed on open-ended responses. This also 73), and around a third were aged between 18 and 30 years old 96 meant that multiple methods and/or reasons for (or against) (37.7%). The majority of the participants described themselves as 97 using different means of suicide could be provided. Further infor- White (92.8%), heterosexual (74.7%), and non-religious (53.0%). 98 mation was gathered about the specific location or locations of sui- All participants reported prior thoughts of suicide. Of these, 686 99 cidal thoughts and behaviours; about suggestions for preventative respondents (49.1%) had experienced suicidal ideation but not 100 measures at different locations; and sociodemographic details (see engaged in suicidal behaviour; 712 (50.9%) reported having 101 Supplementary Appendix available at https://doi.org/10.1192/bjo. engaged in at least one suicide attempt. The latter subsample 102 2021.15 for a copy of the full survey).