Characterizing direct and indirect suicide-related disclosure in the proximal period surrounding an attempt: A qualitative analysis.

OBJECTIVE: Less than half of suicide decedents disclose their suicidal ideation or intent before death. To date, most research has only assessed direct disclosure (i.e., explicitly stating suicidal intent), and may not capture indirect forms of disclosure communicated euphemistically or vaguely (e.g., "I'm worried I'll do something dumb"). Prior evidence suggests that indirect disclosure may serve as a proximal risk factor for suicidal behavior, indicating its importance as a potential point of intervention. METHOD: The current study examines direct and indirect disclosure in 35 adults with substance use problems hospitalized following a suicide attempt. Participants completed interviews where they narrated the story of their attempt. Suicide-related disclosures, as reported spontaneously by participants, were characterized by two coders using qualitative content analysis. Coded features of disclosure included content, directness, function, recipient, and consequences. RESULTS: The majority (60%) of participants reported some form of disclosure, direct or indirect, preceding their hospitalization. The vast majority (95%) of disclosures occurred within 24 h of the attempt. About one-third of reported disclosures were considered indirect, and included behaviors such as communicating distress, asking for help, expressing love, and saying goodbye. For 85% of participants, disclosure was at least partially responsible for the receipt of crisis intervention. CONCLUSIONS: Our findings suggest that indirect disclosure is relatively common in the 24 h surrounding an attempt, indicating its importance as a proximal risk factor for suicidal behavior. Disclosure appears to be a critical precursor to the receipt of crisis intervention. Further research into indirect suicide-related disclosure is warranted.