Implicit measures of suicide vulnerability: Investigating suicide-related information-processing biases and a deficit in behavioral impulse control in a high-risk sample and healthy controls.

OBJECTIVE Relevant implicit markers of suicidal thoughts and behaviors (STBs) have only been studied in isolation with mixed evidence. This is the first study that investigated a suicide attentional bias, a death-identity bias and a deficit in behavioral impulsivity in a high-risk sample and healthy controls. METHOD We administered the Death Implicit Association Test, the Modified Suicide Stroop Task, and a Go/No-Go Task to inpatient suicide ideators (n = 42), suicide attempters (n = 40), and community controls (n = 61). RESULTS Suicide ideators and attempters showed a suicide attentional bias and a death-identity bias compared to healthy controls. Ideators and attempters did not differ in these implicit information-processing biases. Notably, only attempters were more behaviorally impulsive compared to controls; however, ideators and attempters did not significantly differ in behavioral impulsivity. Moreover, implicit scores were positively intercorrelated in the total sample. CONCLUSION In line with the Cognitive Model of Suicide, ideators and attempters display suicide-related information processing biases, which can be considered as implicit cognitive markers of suicide vulnerability. Furthermore, attempters have elevated levels of behavioral impulsiveness. These results are highly relevant in the context of crisis intervention strategies and warrant further research

A suicide attentional bias as implicit cognitive marker of suicide vulnerability in a high-risk sample.

INTRODUCTION Suicide risk assessment based on self-report questionnaires is considered as problematic because risk states are dynamic and at-risk individuals may conceal suicidal intentions for several reasons. Therefore, recent research efforts increasingly focus on implicit risk markers such as the suicide attentional bias (SAB) measured with the Suicide Stroop Task (SST). However, most SST studies failed to demonstrate a SAB in individuals with suicide risk and repeatedly demonstrated insufficient psychometrics of the SST. This study aimed to investigate a SAB using a modified SST (M-SST) and to test its psychometric properties. METHOD We compared n = 61 healthy controls and a high-risk inpatient sample of n = 40 suicide ideators and n = 40 suicide attempters regarding interference scores of positive, negative and suicide-related words. Interference scores were calculated by subtracting the mean reaction time (mean RT) of the neutral words from the mean RT of the suicide-related words (mean RT Suicide -mean RT Neutral), resulting in a suicide-specific interference score. Similarly, interference scores were calculated for the positive and negative words by subtracting the mean RT of neutral words from the mean RT of positive and negative words. RESULTS A Group × Interference ANOVA showed a significant interaction effect (p <.001, ηp2 = .09), indicating that group effects significantly vary across interference type. Post hoc comparisons revealed that both ideators and attempters demonstrated greater interferences only for suicide-related words compared to healthy controls, indicating a SAB in patients, while a difference between ideators and attempters was lacking. The suicide interference score classified with an AUC = 0.73, 95% CI [0.65 - 0.82], p <.001, between controls and patients with STBs. The M-SST demonstrated good internal consistency and convergent validity. DISCUSSION The study adds evidence to the assumptions of the Cognitive Model of Suicide, viewing a SAB as a cognitive marker of suicide vulnerability independently of the engagement in suicidal behavior. The results' clinical implications are discussed in the context of recommended intervention strategies during an acute suicidal state. Future studies with the M-SST should include non-suicidal patient controls to investigate whether a SAB is uniquely related to suicidality

Reasons for Living and Dying in Suicide Attempters: A Two-year Prospective Study

Background: The aim of this study was to explore Reasons for Living (RFL) and Reasons for Dying (RFD) of suicide attempters and their association with current and future suicidal ideation and behavior. Method: The sample consisted of 60 patients who were admitted at a psychiatric emergency unit in Switzerland following an attempted suicide. They received treatment as usual, participated in an assessment interview and completed self-report questionnaires including written RFL and RFD responses, depressive symptoms, and suicide ideation at baseline and 6, 12 and 24 months follow-ups. Outcome measures were suicide ideation and repeated suicide attempts. Multiple imputations were used in order to address missing data. Results: The number of RFD responses was the strongest predictor for increased suicide ideation at baseline. The number of RFL responses was not associated with suicide ideation and reattempts. RFD, depressive symptoms, and baseline suicide ideation predicted subsequent suicide reattempt up to 12 months later in simple regression analyses. Mediation analyses suggested that RFD mediated the effect of depressive symptoms at baseline on suicide ideation at 12-months follow-up. Conclusion: RFL were unrelated to the mental health of study participants and did not function as protective factor against suicide risk. RFD may be an important motivational driver in the suicidal process. Clinical interventions should focus more on the reduction of RFD than on RFL in suicidal individuals

Beyond Symptoms: Typical Plans and Motives of Suicide Attempters Compared to Non-Suicidal Depressive Individuals

Aim: A major depressive episode is still a frequently discussed risk factor of suicidal behaviour. However, current studies suggest that depression is predictive of suicidal ideas but much less of suicidal act (Nock et al., 2009). This implies that suicidal behaviour should not only be seen as a symptom of a depressive disorder, but should be understood as an independent behaviour, which must be examined separately. The present qualitative study focuses on typical Plans and motives of suicide attempters compared to non-suicidal depressive individuals.Methods: Plan Analysis (Caspar, 2007), a clinical case conceptualization approach was used to analyze the instrumental relations between participants' behaviours and the hypothetical Plans and motives "behind" this behaviour. Video taped narrative interviews of 17 suicide attempters and intake interviews of 17 non‐suicidal depressive patients were investigated with the Plan Analysis procedure and a Plan structure was developed for each participant. These were used for establishing a prototypical Plan structure for each clinical group.Results: Results indicate that suicidal behaviour serves various Plans and motives only found in suicide attempters. Furthermore depressive patients pursue interpersonal control strategies which may serve as a protective factor for not evolving suicidal behaviour.Discussion. Findings are discussed with respect to current theoretical models of suicidality as well as implications for suicide prevention

Prototypische Planstrukturen und Selbstregulation bei Suizid

Im Bereich der Suizidforschung gab es in den letzten Jahren vermehrte Anstrengungen suizidales Verhalten anhand von empirischen Risikofaktoren rechtzeitig zu erkennen und Suizide zu reduzieren. Dennoch ist es nach wie vor schwierig, einen Suizidversuch auf individueller Ebene vorherzusagen. Laut der Weltgesundheitsorganisation verliert alle 40 Sekunden ein Mensch auf der Welt sein Leben durch Suizid (WHO, 2014). In diesem Beitrag wird eine qualitative Studie (Brüdern et al., 2015) vorgestellt, die aufzeigt, welche Pläne und Motive eine gelungene Selbstregulation bei Menschen mit einem Suizidversuch verhindern und zu einer suizidalen Krise führen könnten. Es werden praxisrelevante Empfehlungen für die Suizidprävention abgeleitet und hier vorgestellt

PRIMEX-S: Implicit and explicit processes of suicide vulnerability

Self-report measures are a commonly used method for assessing the risk of suicidal thoughts and behavior (STBs) (Kleiman et al., 2023).However, several studies have shown that the use of risk scales failed to predict suicide attempts (Steeg et al., 2018). Therefore, in recent years there has been an increasing interest in the development of more objective behavioural measures in order to assess suicide risk, which may improve the detection and prediction of STBs. Behavioral measures offer the opportunity of capturing implicit cognitive processes that run automatically and unconsciously and are less affected by conflicting intentions. A promising approach for investigating such implicit processes is to assess selective attention toward suicide-specific stimuli. The Suicide Stroop Task (SST) represents a behavioural assessment tool that was developed for measuring an activated suicide-specific network, wherein an increased response latency on suicide-related words indicates a suicide-specific attentional bias. Cha et al. (2010) developed the first computerized SST. that was administered to recent suicide attempters and non-attempter psychiatric controls. Wilson et al. (2019) investigated the psychometric properties of the SST in a recent study that includes seven studies with the SST (N = 875). Results yielded no significant differences in all interference scores for the two-group (attempters vs. non-attempters) and three-group (attempters vs. ideators vs. controls) comparisons, demonstrating poor concurrent validity. They discussed several recommendations in order to improve the test, for example by using a blocked design format and increasing the number of stimuli per word category and critical trials. Thus, to optimize the psychometric properties of the SST, one aim of PRIMEX-S is to develop a modified version of the Suicide Stroop Task (M-SST) by taking the recommendations (e.g. a blocked design format, a greater number of trials and stimuli per word category, more different font colors) of prior SST research into account. We developed a modified version with a neutral, positive, negative, and suicide-related word category. Additionally, we developed an extended version with an additional suicide-related word category, which includes suicide-related positive words (see word material of the extended version). Results of a pilot study testing the extended version are reported in Gold et al. (2024). Within PRIMEX-S, we also applied a Death-Implicit Association Test (D-IAT) to investigate implicit associations with death in suicide attempters (n = 40), suicide ideators (n = 42) and healthy controls (n = 61). Furthermore, we examined deficits in behavioral impulse control with a Go/No-Go (GNG) Task in these three subgroups as a potential marker of suicide vulnerability