Toward Optimizing Behavioral Markers of Suicide Risk

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Despite ongoing efforts to enhance suicide risk assessment, current methods rely heavily on patient report of suicidal ideation and related factors (e.g., intent, plan, access to means) to determine level of risk. Reliance on self-report is problematic because many patients are unwilling or unable to report thoughts and intentions of suicide.1 In addition to these limitations, the emphasis of self-report measures on conscious thoughts and emotions has fostered little insight into the largely unconscious cognitive processes that are theorized to underlie suicidal crises.2,3 These suicide-related cognitive processes, or habitual ways of thinking that promote suicide, are believed to emerge when individuals become distressed, but at other times may be dormant. This notion of “suicidal cognitive reactivity” is consistent with clinicians’ and patients’ observations that for some individuals suicidal thoughts and intentions may be absent during a clinical interview, but then rapidly resurface in the presence of distress. Although suicidal cognitive reactivity is purported to be a critical underlying mechanism of suicide risk, it has received little empirical evaluation because there have not been any established procedures to elicit and assess it. The ability to elicit and assess suicidal cognitive reactivity could be extremely clinically useful. If clinicians could assess the likelihood of suicidal thoughts and intentions emerging in the near future, they would be better able to accurately determine patients’ risk of suicide. We have developed and pilot tested a procedure to evaluate suicidal cognitive reactivity using a suicide-specific mood induction and computerized reaction-time tasks (i.e., the Death/Suicide Implicit Association Test,4 and the Suicide Stroop5) that implicitly measure cognitive processes (i.e., association of self with death, and biased attention toward suicide-related cues) and have predicted suicide attempts among high-risk civilians and Veterans.4,6,7 These tasks serve as behavioral markers of suicide risk. Although promising, the tasks are still not very accurate. This may be due to suicide-related cognitive processes not being active in some participants at the time of assessment. In order to optimize the tasks and test the critical theoretical prediction that distress activates suicidal thinking, the proposed research will examine scores on the Death/Suicide Implicit Association Test and Suicide Stroop task both before and after inducing a dysphoric mood in participants by having them watch a brief scene from a movie having to do with suicide. The study will compare two groups of Veterans: (1) a “Suicide Group” who have or have had a mood anxiety and/or trauma related disorder and have attempted suicide within the past year, and (2) a “No Suicide Group” who similarly have or have/had a mood anxiety and/or trauma related disorder, but have never seriously considered attempting suicide. If the cognitive theory of suicidal behavior2,3 is correct, the Suicide Group will display a significantly larger increase in suicide-related cognitive processes following the mood induction than any increase displayed by the No Suicide Group. Six-months later, participants will complete an interview to determine if they have attempted suicide since the initial assessment session. If utilizing our suicide-specific mood induction does optimize the accuracy of these tasks, the post-mood induction scores from the initial assessment session should predict suicide attempts over and above the pre-mood induction scores and other common indicators of suicide risk (e.g., mental health diagnosis, patient prediction, severity of suicidal ideation). The ability to objectively assess latent processes underlying both suicide risk and resilience among Veterans could significantly contribute to Veterans Health Administration efforts to prevent suicide. Furthermore, results of the proposed study, testing a critical component of one of the field’s most prominent models of suicidal behavior, would inform future research on when, why, and how Veterans are at risk for suicide.