'Flash-forwards' and suicidal ideation: A prospective investigation of mental imagery, entrapment and defeat in a cohort from the Hong Kong Mental Morbidity Survey

•When mental images of suicide are present, suicidal ideation is more severe.•Feeling trapped and imagining escape via suicide predicts suicidal ideation severity.•Resolution of suicidal ideation corresponds to a reduction in suicidal imagery.•Asking patients about mental images of suicide can improve risk assessment.•Suicidal mental imagery could be a novel target for suicide prevention interventions.

'Flash-forwards' - mental images of suicide - have been reported in selected Caucasian samples. Perceptions of defeat and entrapment are considered to be associated with suicidal ideation. We aimed to investigate (1) the presence of suicidal flash-forwards in people with recent suicidal ideation versus those without such ideation in an Asian sample, and (2) associations between suicidal flash-forwards, and perceptions of entrapment accounting for suicidal ideation.Eighty two suicidal and 80 non-suicidal participants from the Hong Kong Mental Morbidity Survey completed questionnaires including suicidal ideation, presence of suicidal flash-forward images, defeat and entrapment, at baseline and seven weeks later.Suicidal 'flash-forwards' were present only in suicidal cases. People with recent suicidal ideation and suicidal flash-forwards had more severe suicidal ideation than those without flash-forwards. Compared to those without suicidal ideation, people with recent suicidal ideation reported higher entrapment and defeat levels. Resolution of suicidal ideation over time was associated with fewer suicidal flash-forwards and reduced entrapment perceptions. At baseline and seven weeks, suicidal ideation was predicted by an interaction between suicidal flash-forwards presence and perceptions of entrapment.Mental imagery of suicide appears to be associated with suicidal ideation, and may represent a novel target in suicidal risk assessment and prevention.

Graphical abstractThe presence of suicidal mental imagery and high levels of entrapment feelings predict greater suicidality.Download high-res image (140KB)Download full-size image