Detecting Suicide Risk Among College Students: A Test of the Predictive Validity of the Modified Emotional Stroop Task

Lower- versus higher-order suicide-related attentional processing measures as predictors of adolescent suicide ideation and attempt

Cognitive theories suggest that biased suicide-related attentional processing confers risk for suicide ideation (SI) and attempts (SAs), but studies to date, which have been mixed, have not compared lower- and higher-order measures of attentional processes. The present study examined attention fixation, attention disengagement, and semantic interference as predictors of future SI and SA among adolescents, a high-risk age group for onset of SI and SAs. Adolescents (N = 135) (75 % female), ages 12-19 (M = 15.4, SD = 1.9), who presented to emergency or outpatient departments with SI (n = 84) or a SA (n = 51) completed an attention disengagement task (ADT), Suicide Stroop task, and the Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ). A subsample of adolescents completed 3-month (n = 98) and 12-month follow-up assessments (n = 96) of SI severity and SA (n = 118) (based on adolescent or caregiver report). AFSEQ score predicted SI severity at 3- and 12-months, respectively, b = 0.47, p < .05; b = 0.44, p < .01, adjusting for ADT and relevant covariates, and also predicted SA at follow up, OR = 1.06, 95 % CI = 1.00-1.12, p < .05, adjusting for SA history, but not after adjusting for SI. Greater suicide-related attention disengagement difficulty predicted greater SI severity at 12 months, b = 0.03, p < .05, but not at 3 months. Self-reported, higher-order, attentional fixation may better predict future suicide-related risk among diverse adolescents than lower-order cognitive tasks assessing suicide-related attention disengagement or semantic interference.

Cognitive control impairment in suicide behaviors: what do we know? A systematic review and meta-analysis of Stroop in suicide behaviors

BACKGROUND

Suicidal behavior results from a complex interplay between stressful events and vulnerability factors, including cognitive deficits. Poorer performance on the Stroop task, a measure of cognitive control, has been associated with suicidal behavior in numerous studies. The objective was to conduct an updated systematic review of the literature on the Stroop task as a neuropsychological test of vulnerability to suicidal acts in patients with mood and other psychiatric disorders, while also looking at how the type (classic versus emotional) or the version (paper or computerized) of the Stroop task, as well as the characteristics of the patient (clinical population, age, sex) moderated the Stroop effect.

METHODS

A search on Medline, Embase, PsycInfo databases, and article references was performed. 53 studies (6781 participants) met the selection criteria. Interference time and errors of the Stroop Test were assessed in at least 3 studies to be analyzed. Moderators, such as the type (classic versus emotional) of the Stroop task and the characteristics of the patient (clinical population, age, sex) were also assessed.

RESULTS

Interference time on Stroop performance was lower in suicide attempters than in patient controls (g = 0.20; 95%CI [0.10-0.30]) and healthy controls (g = 0.79; 95 % CI [0.29-1.29]), with patient controls scoring lower than healthy controls (g = -0.63; 95%CI [-1.01-0.25]). This was moderated by age and having a mood disorder. In terms of interference errors, suicide attempters performed worse than healthy controls (g = 0.57; 95%CI [0.01-1.15]) but did not perform differently from patient controls (g = 0.20; 95 % CI [-0.06-0.45]). Patient controls also did not score differently than healthy controls (g = -0.18; 95 % CI [-0.54-0.18]). There was a significant moderation effect for the type (i.e., original Stroop task) and version (i.e., paper format) of the Stroop task, and for some characteristics of the patient (i.e., older patients and having a mood disorder).

CONCLUSIONS

Cognitive control impairment was associated with a history of suicidal behavior in patients, especially in older populations and those with mood disorders, however this result was moderated by outcome measure (interference time vs. errors), the type (i.e., original Stroop task) and the version (i.e., paper format) of the Stroop task. Cognitive control processes may be an important factor of suicidal vulnerability. Choosing the right neurocognitive test in the right population to detect suicide vulnerability is important direction for future research.

Multi-modal risk factors differentiate suicide attempters from ideators in military veterans with major depressive disorder

BACKGROUND

The suicide rate for United States military veterans is 1.5× higher than that of non-veterans. To meaningfully advance suicide prevention efforts, research is needed to delineate factors that differentiate veterans with suicide attempt/s, particularly in high-risk groups, e.g., major depressive disorder (MDD), from those with suicidal ideation (no history of attempt/s). The current study aimed to identify clinical, neurocognitive, and neuroimaging variables that differentiate suicide-severity groups in veterans with MDD.

METHODS

Sixty-eight veterans with a DSM-5 diagnosis of MDD, including those with no ideation or suicide attempt (N = 21; MDD-SI/SA), ideation-only (N = 17; MDD + SI), and one-or-more suicide attempts (N = 30; MDD + SA; aborted, interrupted, actual attempts), participated in this study. Participants underwent a structured diagnostic interview, neurocognitive assessment, and 3 T-structural/diffusion tensor magnetic-resonance-imaging (MRI). Multinomial logistic regression models were conducted to identify variables that differentiated groups with respect to the severity of suicidal behavior.

RESULTS

Relative to veterans with MDD-SI/SA, those with MDD + SA had significantly higher left cingulum fractional anisotropy, decreased attentional control on emotional-Stroop, and faster response time with intact accuracy on Go/No-Go. Relative to MDD + SI, MDD + SA had higher left cingulum fractional anisotropy and faster response time with intact accuracy on Go/No-Go.

LIMITATIONS

Findings are based on retrospective, cross-sectional data and cannot identify causal relationships. Also, a healthy control group was not included given the study's focus on differentiating suicide profiles in MDD.

CONCLUSIONS

This study suggests that MRI and neurocognition differentiate veterans with MDD along the suicide-risk spectrum and could inform suicide-risk stratification and prevention efforts in veterans and other vulnerable populations.

Differences in suicide-specific attentional bias based on stimuli across the suicide Stroop and disengagement tasks

BACKGROUND

Evidence of suicide-specific attentional bias has been mixed, including the effect of specific suicide words (e.g., "suicide" versus "overdose"). The current study examined the psychometric properties and convergent validity of specific suicide words on the Stroop and disengagement tasks.

METHODS

Adults (79.8 % male, mean age = 42.19 ± 12.66) on a psychiatric inpatient unit completed both tasks, as well as clinical and demographic measures, following a recent suicide attempt (SA) (n = 55) or recent suicidal ideation (SI) with (n = 29) or without (n = 26) a SA history.

RESULTS

Mean reaction times (RTs) on both tasks demonstrated good internal consistency and were moderately correlated across tasks, while interference scores demonstrated poor reliability and were not correlated. Attentional bias to specific suicide words did not differentiate SA groups, except for a small, unexpected effect on the Stroop task showing greater interference to the word "funeral" among the recent SA group. Correlations with suicide risk factors differed for males and females.

LIMITATIONS

Participants all endorsed elevated SI, limiting generalizability beyond a recent suicidal crisis. Different suicide words were used on each task limiting direct comparisons. Groups based on SA history and gender were uneven, and correlations need to be replicated. Effects involving interference scores should be interpreted with caution given poor internal consistency.

CONCLUSION

The suicide Stroop and disengagement tasks partially capture distinct aspects of suicide-relevant attentional bias. Greater attention is needed regarding the particular stimuli and scoring methods as well as the role gender plays in suicide-relevant attentional bias.

Adaptation and validation of a suicide-focused Word Sentence Association Paradigm to assess suicide-specific interpretation biases

The cognitive model of suicide proposes that biased cognitive processes contribute to suicidal thoughts and behaviors, and initial evidence suggests that attentional bias to suicide-congruent cues may predict suicidal behavior beyond established clinical risk factors. To date, much less work has explored the potential role of interpretation biases in the development and prediction of suicide risk. The present study assessed the psychometric properties, including reliability, concurrent validity, and predictive validity, of a novel adaptation of the Word Sentence Association Paradigm (WSAP) to assess suicide-suicide interpretation biases. In a sample of 239 psychiatric inpatients, including patients with no recent suicidal ideation or lifetime attempts (n = 35), those with recent suicide attempts (n = 29), and those with recent suicidal ideation (n = 174), participants completed the modified WSAP as well as self-reported suicidal ideation and attempts for the subsequent 6 months. Although the WSAP demonstrated good reliability, evidence of concurrent and prospective validity (in terms of self-reported suicidal ideation and attempts) was limited. Specifically, the clinical groups did not differ from one another on any measure of interpretation bias, nor did suicide-specific interpretation endorsements predict concurrent or future suicidal ideation when controlling for dysphoric interpretation bias. However, suicide-specific interpretation biases were uniquely associated with a history of a lifetime suicide attempt. Future work should further clarify the extent and specificity of the relationship between suicide-specific interpretation biases and clinical outcomes.

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.

Psychometric properties of the modified Suicide Stroop Task (M-SST) in patients with suicide risk and healthy controls

The Cognitive Model of Suicide proposes a suicide attentional bias in individuals with suicidal thoughts and behavior (STBs). The Suicide Stroop Task (SST) was developed as a behavioral measure to assess this attentional bias. However, prior studies demonstrated poor psychometric properties of the SST.

Methods

We developed a modified Suicide Stroop Task (M-SST) and tested its psychometric properties in a sample of healthy controls (n = 30) and inpatients with STBs (n = 24). Participants (50% female, aged 18 to 61 years) completed the M-SST with neutral, positive, negative, suicide-related positive and suicide-related negative 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 positive words (mean RTSuicide-Positive-mean RTNeutral) and suicide-related negative words (mean RTSuicide-Negative-mean RTNeutral), resulting in two suicide-specific interference scores. 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

When analyzed separately, patients with STBs showed greater interferences for suicide-related positive words (p = 0.039), and for suicide-related negative words (p = 0.016), however, we found no group differences in interference scores for positive and negative words, suggesting a suicide attentional bias in patients with STBs. Controlling for the repeated measure design, a repeated measure ANOVA failed to detect a significant group × interference interaction effect (p = 0.176), which limits the generalizability of the findings. However, the interference score of suicide-related negative words showed an adequate classification accuracy (AUC = 0.72, 95% CI [0.58-0.86], p = 0.006) for differentiating between healthy controls and patients with STBs. Moreover, the interference scores showed acceptable internal reliability for the total sample and only suicide-related interference scores were correlated with clinical characteristics, thus demonstrating convergent validity.

Conclusion

The results provide preliminary evidence for a suicide attentional bias in individuals with STBs compared to healthy controls. The M-SST represents a promising tool for assessing a suicide attentional bias by revealing adequate psychometric properties. Future studies with larger samples are needed to confirm these preliminary findings.

The Suicide Dot Probe Task: Psychometric properties and validity in relation to suicide-related outcomes

BACKGROUND

Attentional biases to suicide-related stimuli have been linked to suicide-related outcomes. However, behavioral tasks that have been previously modified to capture suicide-specific attentional biases have demonstrated inconsistent reliability and validity. Adaptation of the Dot Probe Task, a computerized assessment that has been adapted to study a wide variety of biases, may be a promising candidate for assessing suicide-specific biases.

METHODS

In 280 recently discharged inpatients (51% male; Mage  = 40.22 years), we evaluated the psychometric properties of a modified Suicide Dot Probe Task. Participants completed this task and assessments of suicidal thoughts and behaviors at baseline and 6-month follow-up.

RESULTS

The Suicide Dot Probe Task demonstrated poor-to-moderate internal consistency and poor test-retest reliability, and participant response times were slower to suicide-specific and dysphoric stimuli than positive stimuli. However, there were no differences based on the presence or characteristics of recent or lifetime suicidal ideation or attempts. Participants' suicide-specific biases were not predictive of suicidal ideation or attempts at follow-up.

CONCLUSIONS

The Suicide Dot Probe Task exhibited questionable reliability, and differences in attentional biases were not associated with suicidal ideation or attempts. This study contributes to a body of research demonstrating the questionable utility of several behavioral tasks to study suicide-specific attentional biases.

Toward objective characterizations of suicide risk: A narrative review of laboratory-based cognitive and behavioral tasks

Although suicide is a leading cause of preventable death worldwide, current prevention efforts have failed to substantively mitigate suicide risk. Suicide research has traditionally relied on subjective reports that may not accurately differentiate those at high versus minimal risk. This narrative review supports the inclusion of objective task-based measures in suicide research to complement existing subjective batteries. The article: 1) outlines risk factors proposed by contemporary theories of suicide and highlights recent empirical findings supporting these theories; 2) discusses ongoing challenges associated with current risk assessment tools and their ability to accurately evaluate risk factors; and 3) analyzes objective laboratory measures that can be implemented alongside traditional measures to enhance the precision of risk assessment. To illustrate the potential of these methods to improve our understanding of suicide risk, the article reviews how acute stress responses in a laboratory setting can be modeled, given that stress is a major precipitant for suicidal behavior. More precise risk assessment strategies can emerge if objective measures are implemented in conjunction with traditional subjective measures.

Revised Attentional Fixation on Suicide Experiences Questionnaire and its relationship with suicidal ideation and behavior: A cross-sectional study

INTRODUCTION

The Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) was developed to measure attentional fixation on suicide, a cognitive process characterized by a preoccupation with suicide as a solution. This study investigated a revised version (AFSEQ-R) and examined differences between those who made a recent suicide attempt and those with suicidal ideation (SI).

METHOD

Participants were 57 inpatients who attempted suicide within 14 days of study participation and 57 inpatients who presented with SI but no suicidal behavior within the past year. Analyses examined the internal reliability, multidimensionality, and construct validity of the AFSEQ-R, and whether attentional fixation moderated the correlation between SI and attempt status.

RESULTS

Exploratory factor analysis revealed a two-factor structure, and subscale and total scores demonstrated excellent internal consistency. Cognitive Stuckness (and total score) correlated with SI, anxiety, impulsivity, and specific problem-solving deficits, while Cognitive Dysfunction correlated with anxiety and acted as a moderator of the correlation between Stuckness and SI. AFSEQ-R scores did not moderate the relationship between SI and attempt status.

CONCLUSION

AFSEQ-R is a psychometrically sound and valid measure of attentional fixation. Attentional fixation on suicide is correlated with SI, and prospective studies are needed to uncover its directional effect on suicidal crises.

Adaptation of an Emotional Stroop Test for Screening of Suicidal Ideation in Portugal

Cognitive instruments, especially those with emotional components, may be useful to address the limitations of self-report scales commonly used to assess suicidal ideation. The aim of this study was to develop an emotional Stroop test for screening suicidal ideation in Portugal. The project was developed in five phases using different samples for each phase. The first two phases were focused on the formulation of the potential words that would compose the slides. For this purpose, five biology teachers (neutral slide) and five mental health professionals (positive and negative slides) were invited to help choose the words that were most representative for each slide. The third phase validated the words defined in the previous phase. In this phase, 300 university students participated (M_age = 21.66; SD = 3.67; 68% female). They rated the words on a Likert scale in terms of their frequency of use, familiarity, level of understanding, and degree of image evocation. In the fourth phase, the researchers developed the complete version of the test, which consists of three slides with neutral, positive, and negative emotional stimuli, consecutively. Finally, in the fifth phase, we validated the final version of the test through a comparative study between a clinical group and a non-clinical group, each one composed by 50 participants (M_age = 32; SD = 9.70; 55% female). Results indicated that the clinical group demonstrated significantly higher scores for depression and suicidal ideation and lower scores for the three Stroop tasks. Words related to negative emotions were strongly correlated with suicidal ideation. Finally, the three Stroop slides explained 74.1% of the variance in suicidal ideation. These findings suggest that this test can be a viable complementary measure in the psychological assessment of suicide ideation, and intervention in the field of suicide prevention in Portugal.

Choosing Death Over Survival: A Need to Identify Evolutionary Mechanisms Underlying Human Suicide

The act of killing self contradicts the central purpose of human evolution, that is, survival and propagation of one’s genetic material. Yet, it continues to be one of the leading causes of human death. A handful of theories in the realm of evolutionary psychology have attempted to explain human suicide. The current article analyses the major components of certain prominent viewpoints, namely, Inclusive fitness, Bargaining model, Pain-Brain model, Psychological aposematism, and few other perspectives. The article argues that relatively more weightage has been given to understanding ultimate (the “why”) rather than proximate (the “how”) functionality of suicidal acts. Evolutionary theorists have consistently pointed out that to comprehensively understand a trait or behavior, one needs to delineate not only how it supports survival but also the evolution of the mechanisms underlying the trait or behavior. Existing theories on suicide have primarily focused on its fitness benefits on surviving kin instead of providing evolutionary explanations of the more complex mechanisms leading up to such self-destructive motivations. Thus, the current paper attempts to highlight this gap in theorizing while suggesting probable proximate explanations of suicide which stresses the need to diffuse attention paid to fitness consequences of the act alone. We speculate that such explorations are needed in order to build a robust and comprehensive evolutionary theory of human suicide.

Electrophysiological correlates of interference control in the modified emotional Stroop task with emotional stimuli differing in valence, arousal, and subjective significance

The role of emotional factors in maintaining cognitive control is one of the most intriguing issues in understanding emotion-cognition interactions. In the current experiment, we assessed the role of emotional factors (valence, arousal, and subjective significance) in perceptual and conceptual inhibition processes. We operationalised both processes with the classical cognitive paradigms, i.e., the flanker task and the emotional Stroop task merged into a single experimental procedure. The procedure was based on the presentation of emotional words displayed in four different font colours flanked by the same emotional word printed with the same or different font colour. We expected to find distinct effects of both types of interference: earlier for perceptual and later for emotional interference. We also predicted an increased arousal level to disturb inhibitory control effectiveness, while increasing the subjective significance level should improve this process. As we used orthogonal manipulations of emotional factors, our study allowed us for the first time to assess interactions within emotional factors and between types of interference. We found on the behavioural level the main effects of flanker congruency as well as effects of emotionality. On the electrophysiological level, we found effects for EPN, P2, and N450 components of ERPs. The exploratory analysis revealed that effects due to perceptual interference appeared earlier than the effects of emotional interference, but they lasted for an extended period of processing, causing perceptual and emotional interference to partially overlap. Finally, in terms of emotional interference, we showed the effect of subjective significance: the reduction of interference cost in N450 for highly subjective significant stimuli. This study is the first one allowing for the investigation of two different types of interference in a single experiment, and provides insight into the role of emotion in cognitive control.

New Methods for Assessing Rapid Changes in Suicide Risk

Rapid-acting interventions for the suicide crisis have the potential to transform treatment. In addition, recent innovations in suicide research methods may similarly expand our understanding of the psychological and neurobiological correlates of suicidal thoughts and behaviors. This review discusses the limitations and challenges associated with current methods of suicide risk assessment and presents new techniques currently being developed to measure rapid changes in suicidal thoughts and behavior. These novel assessment strategies include ecological momentary assessment, digital phenotyping, cognitive and implicit bias metrics, and neuroimaging paradigms and analysis methodologies to identify neural circuits associated with suicide risk. This review is intended to both describe the current state of our ability to assess rapid changes in suicide risk as well as to explore future directions for clinical, neurobiological, and computational markers research in suicide-focused clinical trials.

Gender Differences in Mental Health Disorder and Substance Abuse of Chinese International College Students During the COVID-19 Pandemic

Introduction: The outbreak of coronavirus disease has negatively impacted college students' mental health across the world. In addition, substance abuse also is trouble among these students. This study aims to find the gender difference in Chinese international college students' mental health and substance abuse during the COVID-19 pandemic. Method: We conducted an online survey using PHQ-9, GAD-7, and several questions related to substance abuse frequency, self-injury, and suicidal thoughts, 535 male and 475 female Chinese international college students whose ages ranged from 18 to 23 years old (x = 20.19, SD = 1.50) were recruited during the epidemic. We utilized t-test and binary logistic regression in our study to find out the difference and statistical significance between substance abuse issues and mental health problems across gender. Results: Both male and female Chinese international college students had statistical significance with self-injury ideas and behaviors (t = -2.21, p < 0.05). Furthermore, the male college students with anxiety problems had positive statistical significance with medicine (OR = 3.47, 95%CI = 1.45-8.30, p < 0.01) and negative statistical significance with drinks (OR = 0.23, 95%CI = 0.08-0.65, p < 0.01). While for female college students with an anxiety problem, they had positive statistical significance with medicine (OR = 4.88, 95%CI = 1.53-15.57, p < 0.01), drugs (OR = 4.48, 95%CI = 1.41-14.25, p < 0.05) and cigarettes (OR = 6.63, 95%CI = 1.95-22.57, p < 0.01) and negative statistical significance with drinks (OR = 0.18, 95%CI = -0.05 to 0.65, p < 0.01). Conclusion: This is the first cross-sectional study focusing on the Chinese international college students' mental health and substance abuse problems during the COVID-19 pandemic. We found that Chinese international college students' mental health and substance abuse situation has been negatively influenced during this period. In addition, the self-injury ideas and behaviors also showed a high tendency for these students. The findings of our study also highlight the need to find more interventions and preventions to solve the different mental health and substance abuse problems for college students, especially for female Chinese international college students.

Investigating the psychometric properties of the Suicide Stroop Task

Behavioral measures are increasingly used to assess suicidal thoughts and behaviors. Some measures, such as the Suicide Stroop Task, have yielded mixed findings in the literature. An understudied feature of these behavioral measures has been their psychometric properties, which may affect the probability of detecting significant effects and reproducibility. In the largest investigation of its kind, we tested the internal consistency and concurrent validity of the Suicide Stroop Task in its current form, drawing from seven separate studies (N = 875 participants, 64% female, aged 12 to 81 years). Results indicated that the most common Suicide Stroop scoring approach, interference scores, yielded unacceptably low internal consistency (rs = -.09-.13) and failed to demonstrate concurrent validity. Internal consistency coefficients for mean reaction times (RTs) to each stimulus type ranged from rs = .93-.94. All scoring approaches for suicide-related interference demonstrated poor classification accuracy (AUCs = .52-.56) indicating that scores performed near chance in their ability to classify suicide attempters from nonattempters. In the case of mean RTs, we did not find evidence for concurrent validity despite our excellent reliability findings, highlighting that reliability does not guarantee a measure is clinically useful. These results are discussed in the context of the wider implications for testing and reporting psychometric properties of behavioral measures in mental health research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).