Current paradigms of suicide: active and passive ideations as key precursors to attempts

Current paradigms of suicide have importantly sought to understand the transition from the consideration of suicide to attempted suicide. Of the 17 theories/frameworks of suicide that have been published in the past two decades (see Appendix), the majority (>88%) consider suicidal ideation, most often as either a mediator of the relationship between psychological pain and attempted suicide (Duprey et al., Reference Duprey, Handley, Wyman, Ross, Cerulli and Oshri2022; Klonsky & May, Reference Klonsky and May2015) or as a joint outcome with behavior (Bloch-Elkouby et al., Reference Bloch-Elkouby, Yanez, Chennapragada, Richards, Cohen and Galynker2021; Miller & Prinstein, Reference Miller and Prinstein2019). In particular, the field has largely relied on “ideation-to-action frameworks” including the interpersonal-psychological theory (Wolford-Clevenger et al., Reference Wolford-Clevenger, Stuart, Elledge, McNulty and Spirito2020), the interpersonal theory of suicide (Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010), the integrated motivational-volitional model (O’Connor, Reference O’Connor2011), the fluid vulnerability theory (Rudd, Reference Rudd and Ellis2006), and the three-step model of suicide (Klonsky & May, Reference Klonsky and May2015). These frameworks typically treat the onset of active suicidal ideation and the escalation of ideation to attempt as separate phenomena with distinct predictors and moderators. For example, psychological pain and hopelessness are key predictors in the onset of suicidal ideation, but acquired capability and burdensomeness have been named as key elements in transitioning from ideation to attempt (Duprey et al., Reference Duprey, Handley, Wyman, Ross, Cerulli and Oshri2022; Klonsky & May, Reference Klonsky and May2015; O’Connor & Kirtley, Reference O’Connor and Kirtley2018; Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010). This work has been critically important in building a nuanced understanding of the escalation to suicidal actions and has been foundational to guiding a number of highly promising prevention strategies in adolescence and across the life span.

Two theories have especially moved the field forward by considering ideation as two qualitatively distinct suicide-related thoughts – active suicidal ideation (i.e., the serious consideration of killing one’s self) and passive ideation (i.e., the desire to no longer be alive; Klonsky & May, Reference Klonsky and May2015; Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010).

Active suicidal ideation

Most of what we know about the timing of thoughts about life and death in the life span comes from the suicidology literature on active suicidal ideation. The onset of active ideation is somewhat less common before the age of 10 (Ortin-Peralta et al., Reference Ortin-Peralta, Sheftall, Osborn and Miranda2023), with the greatest increases in active suicidal ideation incidence occurring between the ages 12 and 17 (Cha et al., Reference Cha, Franz, Guzmán, Glenn, C., Kleiman and Nock2018; Miller & Prinstein, Reference Miller and Prinstein2019). According to the most recent National Survey on Drug Use and Health (NSDUH) data, adolescents aged 14–17 reported higher rates of active suicidal ideation as compared to all other age cohorts in 2022 (SAMHSA, 2024). Active suicidal ideation reaches its peak at ages 16–17 and rapidly declines after young adulthood, see Figure 1.

Figure 1. Active suicidal ideation past year prevalence by age, 2022.

Furthermore, YRBSS data suggest that more than one in every five (∼22%) high-school aged adolescents reported serious consideration of suicide in the past year in 2021 (Centers for Disease Control and Prevention [CDC], 2023b).

Active suicidal ideation is a strong predictor of suicide attempts in both adolescence and young adulthood (Cantor et al., Reference Cantor, Kingsbury, Warner, Landry, Clayborne, Islam and Colman2023; Castellví et al., Reference Castellví, Lucas-Romero, Miranda-Mendizábal, Parés-Badell, Almenara, Alonso, Blasco, Cebrià, Gili, Lagares, Piqueras, Roca, Rodríguez-Marín, Rodríguez-Jimenez, Soto-Sanz and Alonso2017). Among adolescents who transition from ideation to attempt, the majority do so within one to two years of active suicidal ideation onset (Nock et al., Reference Nock, Green, Hwang, McLaughlin, Sampson, Zaslavsky and Kessler2013). Even among adolescents who never attempt suicide, active suicidal ideation can cause long-term impairment, suffering, and health care costs (Babcock et al., Reference Babcock, Moussa and Diaby2022; Jobes et al., Reference Jobes, Mandel, Kleiman, Bryan, Johnson and Joiner2024; Oppenheimer et al., Reference Oppenheimer, Glenn and Miller2022; Wastler et al., Reference Wastler, Khazem, Ammendola, Baker, Bauder, Tabares, Bryan, Szeto and Bryan2022a), warranting attention as a prevention target by itself.

Most suicide attempts after adolescence are reattempts in clinical populations, with the time intervals between reattempts decreasing with greater frequency of attempted suicide (Cha et al., Reference Cha, Franz, Guzmán, Glenn, C., Kleiman and Nock2018; Goldston et al., Reference Goldston, Daniel, Erkanli, Heilbron, Doyle, Weller, Sapyta, Mayfield and Faulkner2015). In a 2023 meta-analysis, young adults who reported active suicidal ideation and attempts during adolescence had more than twice and five times the odds of attempted suicide during young adulthood, respectively, than young adults without a history of suicidal thoughts and behaviors during adolescence (Cantor et al., Reference Cantor, Kingsbury, Warner, Landry, Clayborne, Islam and Colman2023). In addition, young adults who strongly considered suicide during adolescence had more than three times the odds of reporting active suicidal ideation in young adulthood, adjusting for concurrent mental health disorders, than young adults without a history of suicidal ideation during adolescence (Cantor et al., Reference Cantor, Kingsbury, Warner, Landry, Clayborne, Islam and Colman2023).

Adolescents who report high active suicidal ideation frequency – how often active suicidal ideation occurs in a given time frame; duration – how long active suicidal ideation occurs for; and persistence – the extent to which active suicidal ideation is transient; are among the most likely to transition to attempted suicide (Czyz et al., Reference Czyz, Koo, Al-Dajani, Kentopp, Jiang and King2022; Czyz & King, Reference Czyz and King2015; Erausquin et al., Reference Erausquin, McCoy, Bartlett and Park2019; Miranda et al., Reference Miranda, Ortin-Peralta, Rosario-Williams, Kelly, Macrynikola and Sullivan2022; Miranda et al., Reference Miranda, Ortin-Peralta, Scott and Shaffer2014). Adolescents with a history of attempted suicide – a relatively strong predictor of future suicide attempts (Cantor et al., Reference Cantor, Kingsbury, Warner, Landry, Clayborne, Islam and Colman2023; Castellví et al., Reference Castellví, Lucas-Romero, Miranda-Mendizábal, Parés-Badell, Almenara, Alonso, Blasco, Cebrià, Gili, Lagares, Piqueras, Roca, Rodríguez-Marín, Rodríguez-Jimenez, Soto-Sanz and Alonso2017) – are more likely to report that their recent ideation lasted greater than four hours than adolescents with active suicidal ideation without a history of attempt (Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023). Meanwhile, ecological momentary assessments (EMAs) – self-report assessments (e.g., on mobile devices) at multiple points throughout the day to collect psychological and behavioral data – have revealed notable variability in day-to-day active suicidal ideation among adolescents. Same-day, and not next day, concurrency of active SI thought frequency, duration, and severity is associated with greater risk (e.g., hopelessness) and reduced protective factors (e.g., connectedness) for suicidal behavior (Czyz et al., Reference Czyz, Horwitz, Arango and King2019). In addition, adolescents are at significantly higher odds to report suicidal rumination, or mental fixation on their suicidal thoughts, in the twenty-four hours prior to an attempt as compared to a 24-hour comparison period (King et al., Reference King, Allen, Ahamed, Webb, Casper, Brent, Grupp-Phelan, Rogers, Arango, Al-Dajani, McGuire and Bagge2023).

The content of active suicidal ideations may vary with a history of suicide attempts. In an analysis of two combined study samples of individuals aged 12–19, adolescents with a recent suicide attempt were more likely to think about the process of dying, what would happen to the body (41% vs 29%), and someone finding them after their attempt (40% vs 25%) than adolescents with active suicidal ideation without a history of attempted suicide (albeit not statistically significant; Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023).

Adolescents with active suicidal ideation and a history of attempted suicide endorse greater suicide-related mental imagery in addition to verbal suicide-related cognitions than adolescents with active suicidal ideation without a history of attempted suicide (Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023). In a recent study of psychiatric unit patients, adolescents who reported suicide-related mental imagery had more than twice the odds of having made a suicide attempt when controlling for verbal suicide-related cognitions, as compared to adolescents without suicide-related mental imagery (Lawrence et al., Reference Lawrence, Nesi, Burke, Liu, Spirito, Hunt and Wolff2021).

Active suicidal ideation is shaped by an enhanced sensitivity to social stimuli during adolescence (Crone & Fuligni, Reference Crone and Fuligni2020; Pfeifer et al., Reference Pfeifer, Masten, Borofsky, Dapretto, Fuligni and Lieberman2009). Extant research has identified a robust relationship between exposure, such as through the death of a peer or family member who has died due to suicide, and adolescent active suicidal ideation (Calderaro et al., Reference Calderaro, Baethge, Bermpohl, Gutwinski, Schouler-Ocak and Henssler2022; Holland et al., Reference Holland, Vivolo-Kantor, Logan and Leemis2017), termed as “social transmission” (Hawton et al., Reference Hawton, Hill, Gould, John, Lascelles and Robinson2020). In particular, the family is an interpersonal context for potential exposure and susceptibility (Brent & Melhem, Reference Brent and Melhem2008; Calderaro et al., Reference Calderaro, Baethge, Bermpohl, Gutwinski, Schouler-Ocak and Henssler2022; Holland et al., Reference Holland, Vivolo-Kantor, Logan and Leemis2017; Mann & Rizk, Reference Mann and Rizk2020; O’Reilly et al., Reference O’Reilly, Kuja-Halkola, Rickert, Class, Larsson, Lichtenstein and D’Onofrio2020; Oppenheimer et al., Reference Oppenheimer, Stone and Hankin2018), as well as a protective factor (Galindo-Dominguez & Iglesias, Reference Galindo-Domínguez and Iglesias2023; Boyd et al., Reference Boyd, Quinn, Jones and Beer2021; Kasen & Chen, Reference Kasen and Chen2020; Lo et al., Reference Lo, Kwok, Yeung, Low and Tam2017; Machell et al., Reference Machell, Rallis and Esposito-Smythers2016; Ruiz-Robledillo et al., Reference Ruiz-Robledillo, Ferrer-Cascales, Albaladejo-Blázquez and Sánchez-SanSegundo2019) for adolescent active suicidal ideation. In addition, adolescents with friends who have active suicidal ideation are more likely to report seriously consideration of suicide (Schlagbaum et al., Reference Schlagbaum, Tissue, Sheftall, Ruch, Ackerman and Bridge2021), which is noteworthy given that adolescents endorse disclosing their active suicidal ideation to their close friends or significant others (Holland et al., Reference Holland, Vivolo-Kantor, Logan and Leemis2017). Lastly, the school environment, an interpersonal setting in which adolescents spend a majority of their time, is of particular importance for adolescent attempted suicide, with feelings of school belongingness, safety, norms, and teacher support each associated with reduced likelihood of active suicidal ideation and behavior during adolescence (Ancheta et al., Reference Ancheta, Bruzzese and Hughes2021, Benbenishty et al., Reference Benbenishty, Astor and Roziner2018; Kasen & Chen, Reference Kasen and Chen2020).

Passive suicidal ideation

Recent research in the suicidology literature isolated the latent structure of suicidal thought content in distinguishing passive and active ideation (Wastler et al., Reference Wastler, Khazem, Ammendola, Baker, Bauder, Tabares, Bryan, Szeto and Bryan2022a). In a study of US adults, thoughts that are typically characterized as passive ideation “I wish I could disappear or not exist,” “I wish I were never born,” “My life is not worth living” and “I wish I could go to sleep and never wake up again” strongly loaded onto one factor, while thoughts that included: “Maybe I should kill myself,” “I should kill myself,” and “I am going to kill myself” loaded onto a second factor representing active ideation (Wastler et al., Reference Wastler, Khazem, Ammendola, Baker, Bauder, Tabares, Bryan, Szeto and Bryan2022a). Of course, these factors might look slightly differently among adolescents (see below our discussion of single item vs. multiple item screening tools for adolescents).

This distinguishing between active and passive ideation was critical to articulating pathways from thoughts to behaviors (ideations to attempts) as well as determining which individuals were most at risk. Indeed, the American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care were amended in 2022 to include universal screening of suicide risk for adolescents aged 12 and up (American Academy of Pediatrics [AAP], 2023a). Of the publicly available evidence-based tools AAP recommends (American Academy of Pediatrics [AAP], 2023b), the Ask Suicide-Screening Questions toolkit specifies the need for a full mental health evaluation for individuals who indicate same day active suicidal ideation, but only a brief suicide safety assessment for those with active or passive suicidal ideation that occurred in the past few weeks (National Institute of Mental Health [NIMH], n.d.-a; n.d.-b). Meanwhile, one of the leading suicide screening tools: the Columbia-Suicide Severity Rating scale (Posner et al., Reference Posner, Brown, Stanley, Brent, Yershova, Oquendo, Currier, Melvin, Greenhill, Shen and Mann2011) specifies immediate action for those with active suicidal ideation and intent with or without a specific plan, but not for those with only passive ideation; a distinction that would not have been possible without the foundational theoretical (and empirical) work on suicidal ideation. In each of these scales, passive suicidal ideation is endorsed with a single item. It is important to note, however, that passive suicidal ideation may present in nuanced and varying ways in a subsample of adolescents. In a study of adolescents, an estimated two thirds of adolescents with passive suicidal ideation go undetected when completing a single-item measure of suicidal ideation, as compared to a multi-item assessment (Gratch et al., Reference Gratch, Tezanos, Fernades, Bell and Pollak2022). However, such multi-item assessments are infrequently used, often due to the participant burden.

Unlike the literature on active suicidal ideation, the onset and prevalence of passive suicidal ideation among adolescents remains relatively understudied in national data sets and empirical studies, with the authors of a 2022 systematic review and meta-analysis deciding to exclude passive suicidal ideation as an outcome due to a low number of reported effect sizes in the existing literature among youth (Van Meter et al., Reference Van Meter, Knowles and Mintz2023). Existing evidence does suggest that passive suicidal ideation has its greatest increase and first onset during adolescence, mirroring active ideation (Liu et al, Reference Liu, Bettis and Burke2020). However, passive suicidal ideation may be as or marginally more prevalent than active suicidal ideation during adolescence. Based on a baseline sample collected from the Adolescent Brain Cognitive Development study, more than one in every twenty 9–10-year-olds (6.4%) reported a lifetime history of passive suicidal ideation, as compared to 4.4% reporting lifetime active suicidal ideation (DeVille et al., Reference DeVille, Whalen, Breslin, Morris, Khalsa, Paulus and Barch2020). Similarly, in a study of adolescents aged 11–19 screened in an emergency department, approximately 13.5% of patients reported past month passive suicidal ideation, as compared to 11.3% endorsing past month active suicidal ideation (Rufino et al., Reference Rufino, Kerr, Beyene, Hill, Saxena, Kurian, Saxena and Williams2022). In a recent systematic review and meta-analysis, age was inversely associated with passive ideation prevalence – with adolescents being the most likely of any age cohort to report ever feeling a desire to no longer be alive (Liu et al., Reference Liu, Bettis and Burke2020).

Passive to active ideation: sequential, separate, or synergistic?

In the frameworks that include active and passive suicidal ideation as distinct constructs, the three-step and interpersonal theories of suicide consider the sequence of more than one ideation (Joiner et al., Reference Joiner, Van Orden, Witte and Rudd2009; Klonsky & May, Reference Klonsky and May2015; Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010).

Both the three-step and interpersonal theories conceptualize passive ideation as a sequential, nonconcurrent step preceding the transition from active ideation to attempted suicide. In describing an individual who has daily experiences of pain (e.g., psychological, physical) and hopelessness, Klonsky & May state that if a person’s connectedness is greater than their pain, an “individual may still have passive ideation, but will not progress to active desire for suicide. However, if both pain and hopelessness are present, and connectedness is absent or less than the pain, the individual will have strong suicidal ideation and an active desire to end his or her life” (2015). Similarly, Van Orden et al., present a hypothesis for active suicidal ideation that can only be met if an individual is experiencing passive suicidal ideation in the presence of thwarted belongingness, perceived burdensomeness, and hopelessness (2010). The authors also hypothesize that suicide attempts only occur “in the context of suicidal intent (which results from thwarted belongingness, perceived burdensomeness, and hopelessness regarding both), reduced fear of suicide, and elevated physical pain tolerance (2010).” In other words, passive ideation is conceptualized as occurring first chronologically and directly preceding the transition from active suicidal ideation to attempted suicide termed as a sequential, hierarchical continuum of risk (Wastler et al., Reference Wastler, Bryan and Bryan2022b). A similar conceptualization is used in current empirical analyses of suicidal ideation, with severity implicitly conceptualized as ranging from passive suicidal ideation, to nonspecific active suicidal ideation (i.e., active suicidal ideation without intention), to active suicidal ideation with intent (Ortin-Peralta et al., Reference Ortin-Peralta, Sheftall, Osborn and Miranda2023).

While there is substantial evidence to support the sequential, hierarchical continuum of risk in adults (Liu et al., Reference Liu, Bettis and Burke2020; Wolford-Clevenger et al., Reference Wolford-Clevenger, Stuart, Elledge, McNulty and Spirito2020), not all studies with adolescents do (Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023; Romanelli et al., Reference Romanelli, Sheftall, Irsheid, Lindsey and Grogan2022). In fact, there is emerging evidence in Black adolescent samples that there are at least a small group of individuals whose attempt behavior is not preceded by ideation at all (Romanelli et al., Reference Romanelli, Sheftall, Irsheid, Lindsey and Grogan2022).

Moreover, there is emerging evidence that the co-occurrence of passive and active ideation might have synergistic effects (Reference Wastler, Bryan and Bryan2022b; Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023, Wastler et al., Reference Wastler, Khazem, Ammendola, Baker, Bauder, Tabares, Bryan, Szeto and Bryan2022a): what we term as the concurrent suicidal cognition assumption. In a recent study, adolescents who had a history of a prior suicide attempt had a high duration (>4 hours) of active suicidal ideation and greater odds of passive suicidal ideation (“a wish to die”) than adolescents without a history of suicide attempt (Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023). The concurrence of suicidal ideations is particularly likely among adolescents (as compared with adults), given that adolescence is a period of the highest onset and prevalence of active and passive ideation (SAMHSA, 2024; Liu et al., Reference Liu, Bettis and Burke2020; Nock et al., Reference Nock, Borges, Bromet, Alonso, Angermeyer, Beautrais, Bruffaerts, Chiu, de Girolamo, Gluzman, de Graaf, Gureje, Haro, Huang, Karam, Kessler, Lepine, Levinson, Medina-Mora, Ono, Posada-Villa and Williams2008).

The cognitive theory of suicide (Wenzel & Beck, Reference Wenzel and Beck2008) incorporates insights into how characteristics of suicidal ideations matter in the transition to attempted suicide. The authors hypothesize that the transition from cognitive processes associated with suicidal acts and suicidal behavior occurs when individuals cross a “threshold of tolerance:” when their cognitions are no longer bearable. Cognitive processes associated with suicidal acts include “maladaptive cognitive contents” (e.g., the ideations an individual has about ending their own life) and “information processing biases” (e.g., attentional fixation on suicide-related cues). According to the theory, certain “dispositional vulnerability factors” – the repetitive/ruminative quality of their negative cognitions i.e., in their frequency, intensity, and/or duration– may affect the ways in which individuals perceive the “unbearability” and “hopelessness” of their cognitive states (Holdaway et al., Reference Holdaway, Luebbe and Becker2018; Horwitz et al., Reference Horwitz, Czyz and King2015; Wenzel & Beck, Reference Wenzel and Beck2008; Miranda & Nolen-Hoeksema, Reference Miranda and Nolen-Hoeksema2007).

In the subsequent sections, we outline adolescence as a distinct developmental period for the concurrence of cognitions, not only for suicidal ideations (Miranda et al., Reference Miranda, Ortin-Peralta, Rosario-Williams, Kelly, Macrynikola and Sullivan2022), but also for other, non-suicidal thoughts adolescents have about death and life. We then consider how these non-suicidal cognitions about life and death may play a role in suicide attempts, alongside and in their concurrence with suicidal ideations. In doing so, our goal is to build a theory of adolescent suicide prevention that considers these cognitions in a single unified framework, for which we invite empirical study. We note that when prior research has considered thoughts about life and death, they are conceptualized and measured as risk or protective factors, as being present or not present, with no clear understanding in how the content, timing, and mental imagery of life, mortality, and suicidal cognitions together shape suicide trajectories. We hypothesize that adolescence is a time in which efforts to reduce thoughts concerning suicide (i.e., active and passive suicidal ideation) while addressing non-suicidal mortality and life cognitions may be particularly efficacious in preventing the transition from ideation to attempt.

Non-suicidal mortality cognitions during adolescence

Adolescent death acceptance

Death acceptance is an adolescent’s cognitive awareness of their own mortality and their affective response to this cognition comprising of three components, including neutral acceptance, approach acceptance, and escape acceptance (Wong et al., Reference Wong, Reker and Gesser1994). Neutral acceptance is the view of death as an unchangeable element of life. Death is thought to highlight the finite nature of existing and allows individuals with neutral acceptance to primarily focus on having a life worth living (Wong et al., Reference Wong, Reker and Gesser1994). Approach acceptance is the belief that death will result in a happy afterlife (1994), and is associated with religiosity (Dezutter et al., Reference Dezutter, Luyckx and Hutsebaut2009). Lastly, escape acceptance is the view of death as a welcome alternative to the pain (e.g., psychological, physical) and suffering experienced in life (Wong et al., Reference Wong, Reker and Gesser1994). Endorsement of escape acceptance is associated with greater likelihood of future adolescent active suicidal ideation recurrence and severity (Tezanos et al., Reference Tezanos, Pollak and Cha2021). Furthermore, adolescents with a history of attempted suicide report death as a solution to unsolvable challenges in life as a driver of their suicidal behavior (May et al., Reference May, O’Brien, Liu and Klonsky2016). Important to note is that greater exposure to death, particularly of a parent or loved one, is associated with a stronger attraction to death and lower levels of attraction to life as compared with adolescents without this exposure (Andriessen et al., Reference Andriessen, Draper, Dudley and Mitchell2016; Gutierrez et al., Reference Gutierrez, King and Ghaziuddin1996)

We posit that these non-suicidal cognitions about death (or mortality cognitions) may co-occur alongside suicidal cognitions and together with suicide cognitions, contribute to suicide attempts. We show these hypothesized relations in Figure 2 below.

Figure 2. Suicidal and non-suicidal mortality cognition concurrence during adolescence.

Mortality cognition onset and prevalence

An emerging body of evidence suggests that non-suicidal cognitions about mortality begin to form and are highly prevalent and developmentally typical (for a discussion, see: Oppenheimer et al., Reference Oppenheimer, Glenn and Miller2022) during adolescence and may co-occur with the onset of suicidal ideations described above. Children explore the concept of death through conversations with their parents as early as three years of age (Renaud et al., Reference Renaud, Engarhos, Schleifer and Talwar2015) and gain more sophisticated conceptualizations of their own mortality in their incorporation of scientific knowledge and belief systems by late childhood (Legare et al., Reference Legare, Evans, Rosengren and Harris2012). Research indicates that by the age of 11, adolescents develop a conceptualization of death as inevitable and universal (Berman et al., Reference Berman, Weems and Stickle2006; Kilpatrick et al., Reference Kilpatrick, Hutchinson, Manias and Bouchoucha2022). Importantly, children 3–6 years of age with a history of depression and suicidal ideation frequently have a mature understanding of death (i.e., its universality, irreversibility, applicability, cessation, causality) that is more developmentally similar to adolescents than to their same aged counterparts (Hennefield et al., Reference Hennefield, Whalen, Wood, Chavarria and Luby2019).

Adolescent implicit associations with death

From childhood to adolescence, individuals form abstract, mental representations and related biases for: same-race, religion, gender, and, in this instance: death. Implicit associations for death are the extent to which adolescents classify constructs of death, such as dead, deceased, lifeless, die, and suicide with attributes/indicators of who they are: me, I, myself, mine, and self (Nock et al., Reference Nock, Park, Finn, Deliberto, Dour and Banaji2010). The death implicit association test (d-IAT), for example, relies upon reaction times in classifying self and other with constructs of death, with greater implicit bias being associated with shorter latencies in response (Glenn et al., Reference Glenn, Millner, Esposito, Porter and Nock2019). In a systematic review and meta-analysis, findings indicated that higher d-IAT scores were associated with greater odds of attempted suicide, and was able to discriminate between individuals with and without a history of a suicide attempt (Sohn et al., Reference Sohn, McMorris, Bray and McGirr2021). Among adolescent outpatient samples, d-IAT scores is predictive of the occurrence, but not the frequency, of active suicidal ideation over the course of: three months (Brent et al., Reference Brent, Grupp-Phelan, O’Shea, Patel, Mahabee-Gittens, Rogers, Duffy, Shenoi, Chernick, Caspter, Webb, Nock and King2023) and a year (albeit not significantly when controlling for prior suicidal ideation; Glenn et al., Reference Glenn, Millner, Esposito, Porter and Nock2019). In addition, higher d-IAT scores were higher amongst adolescents with a history of a suicide attempt who reattempted during the period prior to the one-year follow-up assessment (Glenn et al., Reference Glenn, Millner, Esposito, Porter and Nock2019).

Thoughts about life during adolescence

Below, we outline five domains of life cognitions that may warrant additional attention in the field of adolescent suicidology: hope, curiosity, emotional intelligence, social cognition, and meaning making.

Meaning making

Meaning in life encompasses two distinct processes regarding how an adolescent ascribes significance to their existence: the presence of meaning and the search for meaning. Meaning is present if an adolescent perceives their life to have a purpose and value to others, whereas the search for meaning is how adolescents learn to inquire about and establish meaning in their life (Dezutter et al., Reference Dezutter, Waterman, Schwartz, Luyckx, Beyers, Meca, Kim, Whitbourne, Zamboanga, Lee, Hardy, Forthun, Ritchie, Weisskirch, Brown and Caraway2014, Reference Dezutter, Luyckx and Hutsebaut2009; Steger et al., Reference Steger, Frazier, Oishi and Kaler2006). The search for and presence of meaning in life has frequently been utilized as a protective factor in analyses of adolescent suicide (Costanza et al., Reference Costanza, Prelati and Pompili2019), with limited consideration as a cognition. Little is known about how the content of the cognitions of meaning making (i.e., I have a meaningful life, messages from my friends make me excited to wake up in the morning), their timing, such as their concurrence in relation to when suicidal or non-suicidal mortality cognitions occur, and the richness and vividness of their verbal thoughts and/or mental imagery predicts attempted suicide during adolescence, and across the lifespan.

Meaning in life during adolescence is conceptualized and measured in the existing adolescent suicidology literature as a fixed state: of having or not having, searching for or not searching for “meaning in life.” However, adolescents have multiple dimensions in their lives in which they derive meaning. For example, in reconceptualizing resilience, Wexler et al., describe a dynamic process by which marginalized youth within a political and cultural context make personal and collective meaning of oppression and develop a shared purpose and values (Wexler et al., Reference Wexler, DiFluvio and Burke2009). Similarly, Urata proposes a model of personal, relational, social, and religious/spiritual meaning that is formed across a spectrum that includes pre-meaning: the state of being unconscious to perceptions of meaning; meaning in life: having a purpose and daily thoughts that life is fulfilling; supra-meaning: existential beliefs that surpass cognitions; trans-meaning: transcending the dichotomy of meaning and no-meaning; and no-meaning: emptiness in life (Urata, Reference Urata2015). Each example described above illustrates novel directions in understanding the ways in which meaning making occurs during adolescence and its relationship to suicidal ideation.

These five cognitions about life (life ideations) may be associated with reductions in suicidal ideations and non-suicidal mortality cognitions and contribute independently to suicidal behavior, as we show in Figure 3.

Figure 3. Suicidal, non-suicidal mortality, and life cognition concurrence during adolescence.

Life cognition onset and prevalence

As with non-suicidal mortality cognitions, adolescents begin to form thoughts about their life during adolescence that may co-occur with suicidal ideations. Some of these (e.g., meaning) have been considered in discussions of suicide prevention, even if they are often not directly considered in conceptualizations and empirical study of suicide attempts. While adolescents begin to have existential anxieties in early adolescence, it is not until late adolescence that living a life with meaning becomes a primary source of anxiety (Berman et al., Reference Berman, Weems and Stickle2006; Kilpatrick et al., Reference Kilpatrick, Hutchinson, Manias and Bouchoucha2022). In particular, adolescence is a critical period in the development of life goals and values as well as in the establishment of a sense of direction and purpose in life (Kashdan & Steger, Reference Kashdan and Steger2007; Berman et al., Reference Berman, Weems and Stickle2006).

The cognition-to-action framework: a cognitive developmental theory of adolescent suicide

Below, we present the cognition-to-action framework, a cognitive developmental theory of adolescent suicide. The framework, depicted in Figure 4, synthesizes the extant science of cognitions from a review of the developmental science of how adolescents consider suicide, life, and mortality. It is designed as a roadmap for suicide researchers to conceptualize and operationalize the cognitions that have their onset during adolescence and the processes by which cognition shapes attempted suicide and fatality.

Figure 4. The cognition-to-action framework for adolescent suicide prevention.

We view our cognition-to-action framework as a variable-oriented theory – one that introduces, clarifies, and explicates constructs, with presumed relationships that operate between the constructs (Jaccard & Jacoby, Reference Jaccard and Jacoby2019). Variable-oriented theorizing was utilized in order to initiate the broader conceptualization of cognitions adolescents have relevant to attempted suicide beyond suicidal ideation. In particular, the cognition-to-action framework builds off of existing ideation-to-action frameworks to incorporate understandings from the fields of cognitive and developmental psychology to broaden the conceptualization of ideation during adolescence as thoughts about suicide, death, and life that warrant attention in research and programmatic efforts. To that end, our framework seeks to synthesize findings about cognition during adolescence, outline specific dimensions of cognitions, and consider how adolescent cognitions may have long-term implications for suicidal behavior and fatality across the lifespan. More specifically, our framework outlines cognitions that adolescents have about suicide, death, and life termed as adolescent suicidal, mortality, and life cognitions .

Adolescent suicidal cognitions , include active and passive ideation. Meanwhile, adolescent non-suicidal thoughts about death are termed in our model as mortality cognitions . Defenses to death, death anxieties, and acceptance attitudes represent thoughts adolescents have about death that are distinct from suicidal ideations and that are hypothesized to influence and be influenced by adolescent suicidal and life cognitions. Adolescents have thoughts about living and their existence, termed here as adolescent life cognitions, which include hope, curiosity, emotional intelligence/appraisal, social cognition, and meaning making, that are hypothesized to influence and be influenced by adolescent mortality and suicidal cognitions.

The framework also accommodates three types of cognition characteristics: content, timing, and mental imagery. Cognition content includes the types of cognition described above (e.g., suicidal, life, mortality), the nature of the content as implicit or explicit to the adolescent, and the intent of the adolescent to act on their cognition(s); cognition timing includes the onset, frequency, duration, persistence, and concurrence of their cognitions; and cognition imagery are the verbal and non-verbal (mental) nature of the cognitions, as well as their vividness, specificity, and richness.

Adolescent cognitions and behavior (e.g., suicidal cognitions and attempted suicide) have been shown to have long-term implications over the life course (Cantor et al., Reference Cantor, Kingsbury, Warner, Landry, Clayborne, Islam and Colman2023; Castellví et al., Reference Castellví, Lucas-Romero, Miranda-Mendizábal, Parés-Badell, Almenara, Alonso, Blasco, Cebrià, Gili, Lagares, Piqueras, Roca, Rodríguez-Marín, Rodríguez-Jimenez, Soto-Sanz and Alonso2017). The left-facing arrow in the figure between attempts and cognitions reflect nonlinear effects of suicide attempts during adolescence in shaping adolescent life, mortality, and suicide cognitions (Oppenheimer et al., Reference Oppenheimer, Glenn and Miller2022).

Lastly, cognitions tend to be shaped by an adolescent’s interpersonal context (e.g., school, family, peers). Thus, the framework encourages a developmental perspective in the consideration of the adolescent interpersonal context in which cognitions operate.

Below, we provide exemplars of specific, testable, developmental hypotheses that can be elicited from the cognition-to-action (CTA) framework, as well as how researchers can act on these hypotheses in the field of adolescent suicide prevention. These hypotheses by no means reflect an all-encompassing list, but provide the reader with immediate next steps in testing the model.

CTA developmental hypothesis #1: not all life, mortality, and suicide cognition content are of equal importance in the prediction of attempts and fatality; there may be healthy mortality cognitions and harmful life cognitions

In our CTA framework, we outline specific life, non-suicidal mortality, and suicide cognitions that may be involved in the transition from cognition to action, both during adolescence and across the life course. However, as described above, the overwhelming focus of the literature has been placed on a sole cognition: active suicidal ideation, without much attention placed on passive suicidal ideations (Van Meter et al., Reference Van Meter, Knowles and Mintz2023), and non-suicidal mortality and life cognitions. Critical for primary prevention is to identify and understand the strengths and direction of associations of passive suicidal, life, and non-suicidal mortality cognitions with adolescent suicidal behavior: what mortality and life cognitions are harmful, and which are healthy, in the prevention of attempted suicide and mortality. For example, the overwhelming assumption in the field is that the presence of mortality cognitions is harmful. However, that assumes that there is no way to think about death that isn’t harmful during adolescence; we hypothesize that adopting an acceptance toward death that highlights the importance of having a life worth living can be protective against suicide (Wong et al., Reference Wong, Reker and Gesser1994). Similarly, life cognitions are often thought to have a positive valence; we hypothesize that having unrealistic positive future thinking could be harmful for adolescent suicidality (Nam & Cha, Reference Nam and Cha2023; Pollak et al., Reference Pollak, Guzmán, Shin and Cha2021).

CTA developmental hypothesis #2: the relative concurrence of suicide, life, and non-suicidal mortality cognitions matters in the prediction of adolescent suicidal behavior

We hypothesize that in analyses and predictions of adolescent suicide attempts and fatality, there is a left out variable error problem, namely: the consideration of the concurrence of mortality and life cognitions. We hypothesize that not all adolescents who attempt and/or die by suicide are the same. Rather, there are different clusters of adolescents with shared life, mortality, and suicide cognition concurrence, and these clusters differ in their risk for suicide. In understanding the pattern of cognitions for each of these groups, we can better facilitate the development of healthy cognitions and dampen the presence of harmful cognitions. In the figure below, we hypothesize what adolescents with these distinct patterns of cognitions may look like.

Figure 5 is a hypothetical example of the patterns of cognitions that may appear in a person-centered analysis of a universal sample of adolescents based on the frequency of passive suicidal ideation (SI), active SI, life cognitions, and non-suicidal mortality cognitions. Note: for simplicity, we are assuming the life and mortality cognitions displayed in this hypothetical analysis are healthy or beneficial cognitions (e.g., meaning in life; neutral death acceptance; Wong et al., Reference Wong, Reker and Gesser1994), and not negative or harmful cognitions (e.g., unrealistic positive thinking; Nam & Cha, Reference Nam and Cha2023; Pollak et al., Reference Pollak, Guzmán, Shin and Cha2021). Again, for simplicity, we hypothesize eight patterns of suicidal, life, and mortality cognitions that could emerge, each with their own relative level of risk for suicidal behavior and prevention approach. Pattern #1 represents adolescents who do not have or report any suicidal, life, or mortality cognitions. Patterns #2 – 5 are the cognition patterns in which only one cognition is present, while Patterns #6 – 8 are the cognition patterns in which cognitions are co-occurring or concurrent.

Figure 5. A hypothetical person-centered analysis of suicidal ideation, life, and non-suicidal mortality cognitions.

In particular, we hypothesize that adolescents in pattern #5 (high passive, high active, low healthy life, low healthy mortality cognitions) are at the most risk for suicidal behavior for two reasons. First, as described above, we hypothesize that suicidal ideations that co-occur are synergistic in nature and result in higher levels of risk (Reference Wastler, Bryan and Bryan2022b, Wastler et al., Reference Wastler, Khazem, Ammendola, Baker, Bauder, Tabares, Bryan, Szeto and Bryan2022a). Second, the synergistic concurrence of suicidal ideations is occurring with low frequencies of healthy life and mortality cognitions together resulting in a risk profile for suicidal behavior (Kirtley et al., Reference Kirtley, Lafit, Vaessen, Decoster, Derom, Gülöksüz, De Hert, Jacobs, Menne-Lothmann, Rutten, Thiery, van Os, van Winkel, Wichers and Myin-Germeys2022). Meanwhile, we hypothesize that pattern #7 (low passive, low active, high healthy life, high healthy mortality) represent adolescents that are the least likely to attempt suicide. These adolescents do not have any suicidal ideations, and instead have a high frequency of healthy thoughts about their mortality and their life. The other patterns we hypothesize lie in between patterns #5 and #7 in their risk for suicidal behavior. Important to note: adolescents in pattern 8 (high passive, high active, high healthy life, high healthy mortality) although high in passive and active suicidal ideation concurrence, also have co-occurring healthy life and mortality cognitions that result in a reduced likelihood to act on their suicidal ideations. We posit that building concurrence in cognitions – namely helping adolescents to form healthy life and mortality cognitions in addition to their unhealthy suicidal ideations – is one way in which existing therapies are effective in reducing the likelihood of suicide attempt among adolescents with active suicidal ideation and represents a novel direction for primary prevention efforts.

CTA developmental hypothesis #3: the mental imagery of adolescent suicidal, life, and non-suicidal mortality cognitions is predictive of adolescent suicidal behavior

As described above, there has been preliminary work that has examined how the mental imagery of active suicidal ideations (e.g., their vividness, richness, degree of detail, visual nature) is associated with attempted suicide more so than for verbal active suicidal ideation alone (Lawrence et al., Reference Lawrence, Nesi, Burke, Liu, Spirito, Hunt and Wolff2021; Miranda et al., Reference Miranda, Ortin-Peralta, Macrynikola, Nahum, Mañanà, Rombola, Runes and Wasee2023). We hypothesize that the same is true for passive, mortality, and life cognitions. In this hypothesis, we posit that the extent to adolescents have mental imagery of harmful life, death, and suicidal cognitions is predictive of the likelihood they attempt and die of suicide. If true, primary prevention approaches could seek to provide adolescents with opportunities to visualize healthy life and mortality cognitions, as well as in reducing the vividness, richness, and degree of detail in already present suicidal cognitions.

Moving from hypothesis to action

In the sections below, we outline how the field can move from these hypotheses to action for adolescent suicide prevention that warrant attention based on our framework.