Suicide remains a leading cause of death worldwide¹. A key reason for limited progress is inadequate understanding about the transition from suicidal ideation to suicide attempts. This knowledge is important because the majority of instances of suicidal ideation do not lead to suicide attempts. A World Health Organization study found that approximately two-thirds of individuals with suicidal ideation never make a suicide attempt², and a population-based study found that only 7% of individuals with suicidal ideation attempted suicide during the subsequent two years³.

Unfortunately, little is known about when or for whom ideation leads to attempts. For example, psychiatric disorders that predict suicidal ideation only weakly or negligibly predict progression from ideation to attempts². Similarly, in meta-analytic data, variables such as depression and hopelessness are strong correlates of suicidal ideation, but are weakly or negligibly associated with attempts among ideators⁴. Currently, not even a single strong predictor of suicide attempts among ideators has been identified.

To advance suicide knowledge and prevention we must better understand the transition from suicidal ideation to suicide attempts. A response to this need may be provided by the ideation-to-action framework, which suggests that the development of suicidal ideation and the transition from suicide ideation to attempts are distinct processes with distinct predictors and explanations⁵. This framework has implications for suicide research, risk assessment, intervention, and theory.

Regarding research, the framework underscores the need for studies to identify variables that help predict and explain transition from ideation to attempts. Many studies on suicide attempts examine differences between attempters and non-attempters; however, because all (or virtually all) attempters have suicidal ideation, this common research design confounds attempts and ideation, making it impossible to tell what the differences are attributable to. Studies seeking to identify predictors of suicide attempts must in some way control for suicidal ideation; one option is to conduct analyses that test what predicts suicide attempts among those with ideation.

The framework also has implications for risk assessment and prevention. One implication is that suicide risk factors should not comprise a single list, but be organized according to whether they raise risk for suicidal ideation, suicide attempts among ideators, or both. For example, research to date suggests that depression primarily is a risk factor for suicidal ideation, access to lethal means is a risk factor for suicide attempts among those with ideation, and nonsuicidal self-injury increases risk for both. The framework has similar implications for intervention. Specifically, any intervention for suicide risk should be clear about which aspects are meant to reduce suicidal ideation and which are meant to stop transition from ideation to attempts.

The ideation-to-action framework also applies to suicide theory. Historically, different theories of suicide emphasized different factors, such as social isolation, psychological pain, and hopelessness; these theories have been extremely beneficial for guiding research and providing a foundation that informs contemporary theories. At the same time, traditional theories share a common limitation: they tend to treat suicidality as a single phenomenon in need of a single explanation^{1, 6}. As a result, these theories did not provide separate explanations for suicidal ideation and suicide attempts.

In this context, the Interpersonal Theory of Suicide (IPTS)⁷ rep­resents an important theoretical advance. The IPTS provides separate explanations for the development of suicidal ideation and the progression from suicidal ideation to suicide attempts. Specifically, the IPTS suggests that suicidal desire is caused by thwarted belongingness and perceived burdensomeness, whereas progression from suicidal desire to suicide attempts occurs when one has acquired the capability to make a suicide attempt. Thus, the IPTS may be viewed as the first of a new generation of suicide theories that positioned themselves within an ideation-to-action framework⁶.

The most recent ideation-to-action theory is the Three-Step Theory of Suicide (3ST)⁸. In brief, the 3ST suggests that: a) suicidal ideation is caused by the combination of unbearable pain (usually psychological) and hopelessness, b) suicidal ideation is strong when one’s pain exceeds or overwhelms one's connectedness (to valued people, communities, or sources of purpose and meaning), and c) transition from strong suicidal ideation to potentially lethal suicide attempts is facilitated by dispositional, acquired and practical contributors to capability for suicide. Thus, the 3ST is a concise theory that explains suicide in terms of just four variables: pain, hopelessness, connectedness, and suicide capability.

A growing body of research – including studies on correlates of suicidal ideation and suicide attempts, predictors of suicidal ideation and suicide attempts, motivations for suicide, warning signs for suicide and suicide attempts, and means safety interventions – support the validity of the 3ST⁸. As a result, the 3ST has been incorporated into suicide education and prevention programs, including continuing education courses, campus-based suicide prevention programs, and self-help suicide prevention materials⁸.

An advantage of the 3ST is that it provides a context for understanding the impacts of diverse biopsychosocial risk factors and interventions. Specifically, anything that impacts pain, hopelessness, connection, and/or suicide capability would be expected to impact suicide risk. For example, if an antidepressant were to reduce suicide risk, we might hypothesize that this occurs by reducing depression, and thus psychological pain. We might further hypothesize that an improvement in depression may increase one’s sense of hope for the future, and/or enhance one's ability to engage with valued connections. Similarly, the 3ST can be applied to understand elevated risk in various populations. For example, increased suicide risk in transgender individuals is likely due to increased pain, hopelessness, and disconnection caused by widespread prejudice and discrimination, whereas elevated suicide risk in certain medical professionals may be best explained by elevated suicide capability (i.e., knowledge and access to lethal means). Thus, the 3ST can improve understanding of suicide risk across a variety of clinical, social and scientific contexts.

Despite recent theoretical advances, it remains critical for the field to continue to clarify the conditions under which ideation results in attempts. Perhaps the most promising variable to date explaining this progression is suicide capability. As noted above, this construct was first introduced in the IPTS⁷ and subsequently elaborated by the 3ST⁸. In short, because suicide involves the potential for pain, injury and death, and because people are biologically (and arguably evolutionarily) disposed to fear and avoid pain, injury and death, making a suicide attempt requires the capability to overcome these barriers.

Different definitions and measures of suicide capability have been proposed, and much of the evidence is mixed. Perhaps the most robust finding is that risk of attempts among ideators is higher when practical capability is higher (practical capability refers to knowledge of, access to, and expertise with lethal means). This conclusion is supported not only by recent studies demonstrating a relationship of practical capability to suicide attempts⁸, but also by a long history of research showing impacts of access­ to lethal means and means safety interventions on suicide rates⁹.

Moving forward, it is imperative that research better illuminate when and for whom suicidal ideation leads to suicide attempts. This effort requires use of multiple measurements within longitudinal designs so that the ebb and flow of variables that contribute to suicidal ideation and attempts can be captured precisely and accurately. Understanding the phenomena of suicidal ideation and suicide attempts through the ideation-to-action lens will accelerate the development and refinement of essential suicide research, theory and clinical care.

自杀仍然是世界范围内的主要死亡原因¹。进展有限的一个关键原因是对从自杀意念到自杀企图的转变理解不足。这种知识很重要，因为大多数自杀意念不会导致自杀企图。世界卫生组织的一项研究发现，大约三分之二的有自杀意念的人从未尝试过自杀²，而一项基于人群的研究发现，只有 7% 的有自杀意念的人在随后的两年内尝试过自杀³。

不幸的是，很少有人知道什么时候或谁的想法会导致尝试。例如，预测自杀意念的精神疾病只能微弱或微不足道地预测从意念到尝试的进展²。同样，在元分析数据中，诸如抑郁和绝望之类的变量与自杀意念有很强的相关性，但与自杀意念之间的相关性很弱或可以忽略不计⁴。目前，甚至没有发现思想家中自杀企图的单一有力预测因素。

为了提高自杀知识和预防，我们必须更好地理解从自杀意念到自杀企图的转变。对这种需求的回应可能由从想法到行动的框架提供，这表明自杀意念的发展和从自杀意念到企图的转变是不同的过程，具有不同的预测因素和解释⁵。该框架对自杀研究、风险评估、干预和理论有影响。

关于研究，该框架强调需要通过研究来确定有助于预测和解释从构思到尝试的转变的变量。许多关于自杀未遂的研究检验了企图自杀者和未企图自杀者之间的差异；然而，因为所有（或几乎所有）尝试者都有自杀意念，这种常见的研究设计混淆了尝试和意念，使得无法说出差异的原因。试图确定自杀企图预测因素的研究必须以某种方式控制自杀意念；一种选择是进行分析，测试哪些因素可以预测有想法的人的自杀企图。

该框架还对风险评估和预防有影响。一个含义是，自杀风险因素不应包含一个单一的列表，而应根据它们是否会增加自杀意念、想法者之间的自杀企图或两者的风险进行组织。例如，迄今为止的研究表明，抑郁症主要是产生自杀意念的风险因素，获得致命手段是有意念者自杀企图的风险因素，非自杀性自伤会增加两者的风险。该框架对干预有类似的影响。具体而言，任何针对自杀风险的干预措施都应明确哪些方面旨在减少自杀意念，哪些方面旨在阻止从意念到企图的转变。

想法到行动的框架也适用于自杀理论。历史上，不同的自杀理论强调不同的因素，例如社会孤立、心理痛苦和绝望；这些理论对于指导研究和提供为当代理论提供信息的基础非常有益。与此同时，传统理论有一个共同的局限性：他们倾向于将自杀视为一种需要单一解释的单一现象^{1, 6}。因此，这些理论并没有为自杀意念和自杀企图提供单独的解释。

在这种情况下，人际自杀理论 (IPTS) ⁷代表了一个重要的理论进步。IPTS 对自杀意念的发展和从自杀意念到自杀企图的发展提供了单独的解释。具体而言，IPTS 表明，自杀欲望是由受挫的归属感和感知到的负担引起的，而当一个人获得了尝试自杀的能力时，就会发生从自杀欲望到自杀企图的进展。因此，IPTS 可被视为新一代自杀理论中的第一个，将自己定位在从构思到行动的框架^{6 内}。

最新的想法到行动理论是三步自杀理论 (3ST) ⁸。简而言之，第 3ST 建议：a) 自杀意念是由无法忍受的痛苦（通常是心理上的）和绝望的结合引起的，b）当一个人的痛苦超过或压倒一个人的联系（与重要的人、社区或来源）时，自杀意念很强烈。目的和意义），以及 c) 从强烈的自杀意念到可能致命的自杀企图的转变是由性格、后天和实际的自杀能力促成因素促成的。因此，3ST 是一个简明的理论，它仅用四个变量来解释自杀：痛苦、绝望、联系和自杀能力。

越来越多的研究——包括关于自杀意念和自杀企图的相关性、自杀意念和自杀企图的预测因素、自杀动机、自杀和自杀企图的警告信号以及手段安全干预的研究——支持 3ST ⁸的有效性。因此，3ST 已被纳入自杀教育和预防计划，包括继续教育课程、校园自杀预防计划和自助自杀预防材料⁸。

3ST 的一个优势是它为理解不同生物心理社会风险因素和干预措施的影响提供了一个背景。具体而言，任何影响疼痛、绝望、联系和/或自杀能力的事物都会影响自杀风险。例如，如果抗抑郁药要降低自杀风险，我们可以假设这是通过减少抑郁和心理痛苦来实现的。我们可能会进一步假设，抑郁症的改善可能会增加一个人对未来的希望，和/或增强一个人与有价值的联系互动的能力。同样，3ST 可用于了解不同人群的风险升高。例如，跨性别者的自杀风险增加可能是由于疼痛、绝望、以及广泛的偏见和歧视造成的脱节，而某些医疗专业人员的自杀风险升高可能最好通过提高自杀能力（即了解和获得致命手段）来解释。因此，3ST 可以提高对各种临床、社会和科学背景下的自杀风险的理解。

尽管最近的理论取得了进展，但该领域仍然必须继续阐明构思导致尝试的条件。也许迄今为止解释这种进展的最有希望的变量是自杀能力。如上所述，该构造首先在 IPTS ^{7 中}引入，随后由 3ST ⁸详细说明。简而言之，因为自杀涉及潜在的疼痛、伤害和死亡，并且因为人们在生物学上（并且可以说是进化上的）倾向于恐惧并避免疼痛、伤害和死亡，所以尝试自杀需要克服这些障碍的能力。

已经提出了不同的自杀能力定义和衡量标准，而且很多证据是混合的。也许最有力的发现是，当实践能力较高时，创意者之间尝试的风险更高（实践能力是指对致命手段的了解、获取和专业知识）。这一结论不仅得到了近期研究的支持，证明了实践能力与自杀企图的关系⁸，而且长期研究表明获得致命手段和手段安全干预对自杀率的影响⁹也支持这一结论。

展望未来，研究必须更好地阐明自杀意念何时以及为谁导致自杀企图。这项工作需要在纵向设计中使用多次测量，以便可以准确地捕捉导致自杀意念和企图的变量的潮起潮落。通过从想法到行动的视角了解自杀意念和自杀企图的现象，将加速基本自杀研究、理论和临床护理的发展和完善。