Decision-Making in Suicidal Behavior: The Protective Role of Loss Aversion

Differences in Cold and Hot Decision-Making between Gambling and Other Addictions

Behavioral and biological addictions can impair decision-making processes, mainly by means of a dysfunction in brain regions associated with reward and frontal areas that may lead to disadvantageous choices. Understanding these differences helps establish appropriate terminology and enhances our ability to recognize, prevent, and treat these disorders effectively. Thus, while behavioral and biological addictions share some common elements, their underlying mechanisms and impact on decision-making vary significantly. Moreover, decision-making can be measured through questionnaires (stable or "cold" measures) or dynamic tasks (hot decisions) such as the Iowa Gambling Task (IGT), which can reflect different dimensions of this process. The aim of this study was to compare decision-making from different perspectives-stable and dynamic measures-in patients with gambling addiction (GA) (n = 42) and patients with biological addictions (BA) (n = 43). Decision-making was assessed using GDMS (Decisional Styles) and the LCT (Loss Aversion), as cold decision-making measures, as well as a hot or situational task called the IGT (Iowa Gambling Task). The results revealed that GA patients exhibited lower rational style scores compared to BA patients. Additionally, GA patients showed greater loss aversion according to the LCT questionnaire. On the other hand, when analyzing the IGT results, no differences were observed between groups in the overall IG index, learning curves, or the loss aversion parameter. However, GA patients showed higher sensitivity to feedback and less consistency in their decisions. These findings highlight the differences between different types of addictions and highlight the importance of considering the type of measure used to evaluate decision-making.

Attention-deficit hyperactivity disorder in adults with epilepsy: An indirect relationship with suicide risk

PURPOSE

Studies on attention-deficit hyperactivity disorder (ADHD) are scarce in adults with epilepsy. This study aimed to investigate the risk factors for ADHD and determine whether ADHD is directly associated with the risk of suicide in adults with epilepsy.

METHODS

ADHD was assessed using the Structured Clinical Interview for the DSM-5 Disorders Clinical Version. The Mini International Neuropsychiatric Interview (MINI) Plus 5.0.0, Neurological Disorders Depression Inventory for Epilepsy (NDDIE), and Generalized Anxiety Disorder-7 (GAD-7) were also used. Suicide risk was defined as a MINI suicidality score of ≥ 1. Stepwise logistic regression and mediation analyses were conducted.

RESULTS

Of the 157 adults with epilepsy, 19 (12.1 %) were diagnosed with ADHD, including inattentive (5.7 %), hyperactive (3.8 %), and combined (2.5 %) types. Thirty-two subjects (20.4 %) had a risk of suicide. ADHD was insignificantly associated with any epilepsy-related factors. The diagnosis of ADHD was not associated with suicide risk independent of NDDIE ≥ 14 and GAD-7 ≥ 7. Mediation effects of ADHD on suicidality using NDDIE ≥ 14 (odds ratio [OR] 2.850, 95 % confidence interval [CI] 1.398-5.811, p = 0.004) or GAD-7 ≥ 7 (OR 3.240, 95 % CI 1.537-6.828, p = 0.002) were statistically significant, with the proportion mediated being 84.5 % or 92.0 % of the total ADHD effect, respectively. These models were adjusted for age, sex, and composite epilepsy severity scores.

CONCLUSIONS

ADHD was diagnosed in 12.1% of adults with epilepsy and was not associated with any epilepsy-related factors. ADHD was indirectly associated with the risk of suicide resulting from depression and anxiety in adults with epilepsy.

Functional Abnormality of the Reward System in Depressed Adolescents and Young Adults with and without Suicidal Behavior

OBJECTIVE

To identify local and functional connectivity abnormalities in the brain's reward network in depressed adolescents and young adults with and without suicidal behavior.

METHODS

Magnetic resonance imaging data were obtained from 41 major depressive disorder (MDD) patients with suicidal behavior (sMDD, males/females: 12/29), 44 MDD patients without suicidal behavior (nMDD, males/females: 13/32), and 52 healthy controls (HCs, males/females: 17/35). The Young Mania Scale, Hamilton Depression Scale, Columbia Suicide Scale, and Scale for Suicide Ideation were used to evaluate emotional state and suicidal ideation and behaviors. The amplitude of low frequency fluctuations (ALFF), regional homogeneity (ReHo) and functional connectivity of 11 regions of interest (ROIs) in the reward network were determined.

RESULTS

ALFF values in the vmPFC of the nMDD group were significantly lower than those in the HC group (p = 0.031). The ReHo values of the nMDD group were lower in the lVS but higher in the vmPFC than those of the HC group (P = 0.018 and 0.025, respectively). Functional connectivity of the AC with the vmPFC, lVS, rVS, and vmPFC was increased in the sMDD group compared with that in the nMDD group (P = 0.038, 0.034, 0.006, respectively).

CONCLUSION

Local and functional connectivity abnormalities in the reward network were found in the MDD groups. However, increased functional connectivity was found in only the sMDD group.

Potential neuropsychological mechanism involved in the transition from suicide ideation to action - a resting-state fMRI study implicating the insula

BACKGROUND

Understanding the neural mechanism underlying the transition from suicidal ideation to action is crucial but remains unclear. To explore this mechanism, we combined resting-state functional connectivity (rsFC) and computational modeling to investigate differences between those who attempted suicide(SA) and those who hold only high levels of suicidal ideation(HSI).

METHODS

A total of 120 MDD patients were categorized into SA group (n=47) and HSI group (n=73). All participants completed a resting-state functional MRI scan, with three subregions of the insula and the dorsal anterior cingulate cortex (dACC) being chosen as the region of interest (ROI) in seed-to-voxel analyses. Additionally, 86 participants completed the balloon analogue risk task (BART), and a five-parameter Bayesian modeling of BART was estimated.

RESULTS

In the SA group, the FC between the ventral anterior insula (vAI) and the superior/middle frontal gyrus (vAI-SFG, vAI-MFG), as well as the FC between posterior insula (pI) and MFG (pI-MFG), were lower than those in HSI group. The correlation analysis showed a negative correlation between the FC of vAI-SFG and psychological pain avoidance in SA group, whereas a positive correlation in HSI group. Furthermore, the FC of vAI-MFG displayed a negative correlation with loss aversion in SA group, while a positive correlation was found with psychological pain avoidance in HSI group.

CONCLUSION

In current study, two distinct neural mechanisms were identified in the insula which involving in the progression from suicidal ideation to action. Dysfunction in vAI FCs may gradually stabilize as individuals experience heightened psychological pain, and a shift from positive to negative correlation patterns of vAI-MFC may indicate a transition from state to trait impairment. Additionally, the dysfunction in PI FC may lead to a lowered threshold for suicide by blunting the perception of physical harm.

Time and risk preferences and the perceived effectiveness of incentives to comply with diabetic retinopathy screening among older adults with type 2 diabetes

Behavioral economics has the potential to inform the design of incentives to improve disease screening programs by accounting for various behavioral biases. We investigate the association between multiple behavioral economics concepts and the perceived effectiveness of incentive strategies for behavioral change among older patients with a chronic disease. This association is examined by focusing on diabetic retinopathy screening, which is recommended but very variably followed by persons living with diabetes. Five time and risk preference concepts (i.e., utility curvature, probability weighting, loss aversion, discount rate, and present-bias) are estimated simultaneously in a structural econometric framework, based on a series of deliberately-designed economic experiments offering real money. We find that higher discount rates and loss aversion and lower probability weighting are significantly associated with lower perceived effectiveness of intervention strategies whereas present-bias and utility curvature have an insignificant association with it. Finally, we also observe strong urban vs. rural heterogeneity in the association between our behavioral economic concepts and the perceived effectiveness of intervention strategies.

Reliability of Decision-Making and Reinforcement Learning Computational Parameters

Computational models can offer mechanistic insight into cognition and therefore have the potential to transform our understanding of psychiatric disorders and their treatment. For translational efforts to be successful, it is imperative that computational measures capture individual characteristics reliably. Here we examine the reliability of reinforcement learning and economic models derived from two commonly used tasks. Healthy individuals (N = 50) completed a restless four-armed bandit and a calibrated gambling task twice, two weeks apart. Reward and punishment learning rates from the reinforcement learning model showed good reliability and reward and punishment sensitivity from the same model had fair reliability; while risk aversion and loss aversion parameters from a prospect theory model exhibited good and excellent reliability, respectively. Both models were further able to predict future behaviour above chance within individuals. This prediction was better when based on participants' own model parameters than other participants' parameter estimates. These results suggest that reinforcement learning, and particularly prospect theory parameters, as derived from a restless four-armed bandit and a calibrated gambling task, can be measured reliably to assess learning and decision-making mechanisms. Overall, these findings indicate the translational potential of clinically-relevant computational parameters for precision psychiatry.

Resistance to Sunk Cost Propensity Moderate Relationship between Negative Life Event and Hopelessness

Previous research has found that a negative life event is a main risk factor for hopelessness, which in turn is considered to be a proximal cause of major depression disorder and a suicide risk factor. Unfortunately, very little attention has been paid to the role of decision-making constructs between negative life events and hopelessness. To fill this gap, the present study aims to test the moderation role of sunk cost propensity in this relationship, which is an over-generalized tendency to persist, based on past investment. A total of 495 university students completed assessment of their resistance to sunk cost propensity, whereas the negative life events, hopelessness, mental health state (depression, anxiety) and big-five personality traits were measured by various questionnaires. Participants' tendency to resist sunk cost propensity moderated the relationship between negative life events and hopelessness. Individuals who tended to resist sunk cost bias are more vulnerable to the adverse effects of negative life events. This effect is still significant, even after controlling for individuals' psychological well-being (depression, anxiety) and big-five personality traits. The current findings provide preliminary evidence that resistance to sunk cost propensity may be an important characteristic associated with an individual's hopelessness when exposed to a negative life event.

Investigating the Clinical Profile of Suicide Attempters Who Used a Violent Suicidal Means

In our study, we aimed to explore the profile of the high-risk subgroup of suicide attempters that used a violent means compared to suicide attempters that chose a non-violent suicide means. Therefore, we recruited a sample of inpatients with recent suicide attempts in three psychiatric hospitals in Thuringia, Germany. We used a structured clinical interview to assess the psychiatric diagnoses, sociodemographic data, and characteristics of the suicide attempt. Furthermore, we used several validated clinical questionnaires to measure suicidal ideations, suicide intent, depression severity, hopelessness, impulsivity, aggression, anger expression, and childhood trauma. We compared 41 individuals using violent means to 59 using non-violent means with univariate and multivariate statistical analyses. We found significantly (corrected for multiple comparisons) higher levels of impulsivity-related sensation-seeking in violent suicide attempters in univariate and multivariate analyses, and additionally in anger expression directed inward at an uncorrected statistical threshold. Besides that, there were no significant differences between the two groups. We assume that underlying neurocognitive mechanisms, such as impaired decision-making processes and/or differences in risk/loss assessment, could explain the higher levels of questionnaire-based sensation-seeking in subjects who use violent suicide means. Further research is needed, including neuroimaging and biochemical techniques, to gain more insight into the mechanisms underlying the choice of a suicidal means.

Decision-making biases in suicide attempters with major depressive disorder: A computational modeling study using the balloon analog risk task (BART)

BACKGROUND

In the last decade, suicidality has been increasingly theorized as a distinct phenomenon from major depressive disorder (MDD), with unique psychological and neural mechanisms, rather than being mostly a severe symptom of MDD. Although decision-making biases have been widely reported in suicide attempters with MDD, little is known regarding what components of these biases can be distinguished from depressiveness itself.

METHODS

Ninety-three patients with current MDD (40 with suicide attempts [SA group] and 53 without suicide attempts [NS group]) and 65 healthy controls (HCs) completed psychometric assessments and the balloon analog risk task (BART). To analyze and compare decision-making components among the three groups, we applied a five-parameter Bayesian computational modeling.

RESULTS

Psychological assessments showed that the SA group had greater suicidal ideation and psychological pain avoidance than the NS group. Computational modeling showed that both MDD groups had higher risk preference and lower ability to learn and adapt from within-task observations than HCs, without differences between the SA and NS patient groups. The SA group also had higher loss aversion than the NS and HC groups, which had similar loss aversion.

CONCLUSIONS

Our BART and computational modeling findings suggest that psychological pain avoidance and loss aversion may be important suicide risk factor that are distinguishable from depression illness itself.

A Systematic Review of Behavior-Outcome Psychological Assessments as Correlates of Suicidality

AIM

Identifying correlates of suicidality is an important goal for suicide researchers because these correlates may predict suicidal behaviors. Psychological tasks that assess sensitivity to the outcomes of actions (i.e., consequence-based learning) have been commonly used by researchers seeking to identify correlates of suicidality. This is likely due to the straightforward integration of the tasks within most theoretical frameworks for understanding suicidality. Contextual factors have been shown to have a substantial effect on responding in behavior-outcome tasks. However, the direct relevance of these factors as determinants of behavior in suicide research is not clear. Thus, the purpose of this review was to assess the role of context in tasks involving behavior-outcome relations in suicide research.

METHODS

Four databases were searched using terms from general learning theory. Articles that featured evaluation of tasks with hypothetical or real outcomes to differentiate suicidality were included.

RESULTS

Eighty-two studies met inclusion criteria. Across studies there were 27 different tasks. Most instances of tasks across studies involved rewards (76.9%), while others emphasized punishment (15.7%), social (5.6%), or virtual suicide (1.8%) outcomes. Differentiation of suicidality was detected by 43.4%, 64.7%, 83.3%, and 50% of tasks featuring reward, punishment, social contexts, and virtual suicide respectively. All but five studies were retrospective.

CONCLUSION

Tasks that more closely mimic contexts and outcomes related to suicide appear to produce more pronounced differentiation of people with suicidality from people without suicidality. The lack of prospective designs is an important limitation of the literature.HIGHLIGHTSTasks that involve punishment or social outcomes better discriminate suicidality.Reward-based tasks are overused in suicide research.The conditioning hypothesis of suicidality is closely aligned with the literature.Only 5 of 82 studies incorporated prospective measures.

An experimental investigation of the influence of loneliness on changes in belongingness and desire to escape

OBJECTIVE

Loneliness is a well-established risk factor for suicide in young adults, but the mechanisms involved are still unclear. Drawing on the Interpersonal Theory of Suicide, the Evolutionary Model of Loneliness, and Prospect Theory, we examined if high and low levels of loneliness are associated with different patterns of response to losses or gains of belongingness.

METHODS

A sample of 188 students completed the UCLA-Loneliness scale (version 3) and measures of suicide risk. Participants in the top and bottom tertiles of loneliness scores completed a computerized task designed to induce changes (gains, losses) or consistency in risk factors for suicide (belongingness, burdensomeness) over time, and examined the effect on desire to quit the task.

RESULTS

The results showed that the high loneliness group exhibited a larger magnitude of effect on desire to quit from gaining belongingness than for losing belongingness. In contrast, the low loneliness group showed a larger change in desire to quit from losing belongingness than gaining belongingness.

CONCLUSION

The findings provide preliminary experimental support for distinct profiles of suicide risk based on prevailing levels of loneliness. The findings are discussed in relation to a need for increased precision in theoretical models of suicide and loneliness.

Anhedonia and Suicide

Suicide is a leading cause of death, and presently, there is no definitive clinical indicator of future suicide behaviors. Anhedonia, a transdiagnostic symptom reflecting diminished ability to experience pleasure, has recently emerged as a risk factor for suicidal thoughts and behaviors (STBs). This overview, therefore, has the following aims. First, prior research relating anhedonia to STBs will be reviewed, with a particular focus on clarifying whether anhedonia is more closely associated with suicidal thoughts versus behaviors. Second, the National Institute of Mental Health's Research Domain Criteria Positive Valence Systems provide a useful heuristic to probe anhedonia across different units of analysis, including clinical symptoms, behaviors, neural mechanisms, and molecular targets. Accordingly, anhedonia-related constructs linked to STBs will be detailed as well as promising next steps for future research. Third, although anhedonia is not directly addressed in leading suicide theories, this review will provide potential inroads to explore anhedonia within diathesis-stress and interpersonal suicide frameworks. Last, novel approaches to treat anhedonia as a means of reducing STBs will be examined.

Decision-making and cognitive control in adolescent suicidal behaviors: a qualitative systematic review of the literature

Suicide and suicidal behaviors represent a leading cause of morbidity and mortality during adolescence. While several lines of evidence suggest that suicidal behaviors are associated with risky decisions and deficient cognitive control in laboratory tasks in adults, comparatively less is known about adolescents. Here, we systematically reviewed the literature on the association between these neurocognitive variables and adolescent suicidal behaviors. The online search strategy identified 17 neurocognitive studies examining either cognitive control or decision-making processes in adolescents with past suicidal behaviors. Several studies have reported that adolescents with a history of suicidal behaviors present neuropsychological differences in the cognitive control (using Go/NoGo, suicide Stroop Test, continuous performance test, suicide/death Implicit Association Test), and decision-making (Iowa Gambling Task, Cambridge Gambling Task, cost computation, delay discounting, loss aversion tasks) domains. Due to a lack of replication or conflicting findings, our systematic review suggests that no firm conclusion can be drawn as to whether altered decision-making or poor cognitive control contribute to adolescent suicidal behaviors. However, these results collectively suggest that further research is warranted. Limitations included scarcity of longitudinal studies and a lack of homogeneity in study designs, which precluded quantitative analysis. We propose remediating ways to continue neuropsychological investigations of suicide risk in adolescence, which could lead to the identification of novel therapeutic targets and predictive markers, enabling early intervention in suicidal youth.

Emotional stress & decision-making: an emotional stressor significantly reduces loss aversion

Stress influences loss aversion, the principle that losses loom larger than gains, although the nature of this relationship is unclear. Studies show that stress reduces loss aversion; however, stress response has been only studied by means of physiological measures, but the stressor emotional impact remained unclear. Since emotions can modify stress response and increase the activity of the loss aversion neural substrates, it could be expected that an emotional stressor may produce the opposite effect, i.e. loss aversion increase. 69 participants were divided into experimental and control group. The first one was exposed to emotional stress through a 5-minutes video, and control group viewed a match-length distractor video. Physiological stress response was assessed by means of electrodermal activity (EDA), and both perceived stress, and negative affect (i.e. psychological stress response) were registered through questionnaires. Both groups performed a mixed gamble task, which allowed the extraction of loss aversion through a Bayesian-computational model. During and after video, experimental group had higher electrodermal activity, perceived stress, and negative affect than controls, suggesting that emotional stress induction was effective. However, rather than increasing, loss aversion of stressed participants was lower. These results constitute a new evidence of emotional stress influencing loss aversion and highlight that stress, regardless of its emotional impact, can reduce this phenomenon. These results should be considered when predicting risky decisions.

Decision-making in suicidal behavior: A systematic review and meta-analysis

Impaired decision-making (DM) is well-known in suicidal behavior (SB). We aimed to review the evidence on DM and its mediating factors in SB and perform a meta-analysis on DM assessed using the Iowa Gambling Task (IGT). We conducted a search on databases of papers published on DM and SB up to 2020: 46 studies were included in the systematic review, and 18 in the meta-analysis. For meta-analysis, we compared DM performance between suicide attempters (SAs) and patients (PCs) or healthy controls (HCs). The systematic review showed that SAs have greater difficulties in all DM domains. The meta-analysis found worse IGT performance among SAs in comparison with PCs and HCs. A meta-regression did not find differences for age, gender, psychiatric disorder, and clinical status. Our findings indicate that SAs exhibited deficits in DM under conditions of risk though not ambiguity. Worse DM was independent of age, gender, psychiatric disorder, and suggested that DM impairment could be considered a cognitive trait of suicidal vulnerability, a risk factor and an attribute of SAs.

Highlighting psychological pain avoidance and decision-making bias as key predictors of suicide attempt in major depressive disorder-A novel investigative approach using machine learning

OBJECTIVE

Predicting suicide is notoriously difficult and complex, but a serious public health issue. An innovative approach utilizing machine learning (ML) that incorporates features of psychological mechanisms and decision-making characteristics related to suicidality could create an improved model for identifying suicide risk in patients with major depressive disorder (MDD).

METHOD

Forty-four patients with MDD and past suicide attempts (MDD_SA, N = 44); 48 patients with MDD but without past suicide attempts (MDD_NS, N = 48-42 of whom with suicide ideation [MDD_SI, N = 42]), and healthy controls (HCs, N = 51) completed seven psychometric assessments including the Three-dimensional Psychological Pain Scale (TDPPS), and one behavioral assessment, the Balloon Analogue Risk Task (BART). Descriptive statistics, group comparisons, logistic regressions, and ML were used to explore and compare the groups and generate predictors of suicidal acts.

RESULTS

MDD_SA and MDD_NS differed in TDPPS total score, pain arousal and avoidance subscale scores, suicidal ideation scores, and relevant decision-making indicators in BART. Logistic regression tests linked suicide attempts to psychological pain avoidance and a risk decision-making indicator. The resultant key ML model distinguished MDD_SA/MDD_NS with 88.2% accuracy. The model could also distinguish MDD_SA/MDD_SI with 81.25% accuracy. The ML model using hopelessness could classify MDD_SI/HC with 94.4% accuracy.

CONCLUSION

ML analyses showed that motivation to avoid intolerable psychological pain, coupled with impaired decision-making bias toward under-valuing life's worth are highly predictive of suicide attempts. Analyses also demonstrated that suicidal ideation and attempts differed in potential mechanisms, as suicidal ideation was more related to hopelessness. ML algorithms show useful promises as a predictive instrument.

Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions

INTRODUCTION

Suicide is a global mental health problem for people of all ages. While rates of suicide in children and adolescents are reported as lower than those in older populations worldwide, they represent the third leading cause of death in 15-19-year-olds. The rates are higher among boys than girls worldwide, though the death rates for girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a general decrease in adolescent suicide rates over recent decades. However, increases are reported in South East Asia as well as South America over the same time period.

METHODS

A narrative review method has been used to summarize current knowledge about risk and protective factors for suicide among children and adolescents and to discuss evidence-based strategy for suicide prevention in this age group.

RESULTS

Identified suicide risk and protective factors for children and adolescents largely overlap with those for adults. Nevertheless, developmental characteristics may strengthen the impact of some factors, such as decision-making style, coping strategies, family and peer relationships, and victimization. The implementation of evidence-based suicide preventive strategies is needed. Restricting access to lethal means, school-based awareness and skill training programs, and interventions delivered in clinical and community settings have been proven effective. The effectiveness of gatekeeper training and screening programs in reducing suicidal ideation and behavior is unproven but widely examined in selected settings.

DISCUSSION

Since most studies have been conducted in western countries, future research should assess the effectiveness of these promising strategies in different cultural contexts. The use of more rigorous study designs, the use of both short- and long-term follow-up evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation of online intervention, and the analysis of programs' cost-effectiveness are also required.

From motivation, decision-making to action: An fMRI study on suicidal behavior in patients with major depressive disorder

OBJECTIVE

We explored the neural mechanisms underlying disadvantageous risk decision making in un-medicated major depressive disorder patients who had recent suicide attempts.

METHODS

53 patients with major depressive disorder (MDD), including 23 with a history of suicide attempts (SA) and 30 without (NS), and 30 healthy controls (HCs) completed pertinent psychometric assessments, and the dynamic decision making balloon analogue risk task (BART) under fMRI. We also built a 4-parameter Bayesian computational modeling for decision making analyses.

RESULTS

Several distinct findings emerged. First, SA patients had no depression intensity difference but higher pain avoidance in psychometrics, and more risk aversion in the BART when compared to the NS patients, with computational modeling confirming such reduced risk-taking propensity. Second, SA patients showed smaller left insular cortex activation than NS patients during the high risk, decisional phase of BART, and the modulation correlated with pain avoidance in both SA and NS groups. Third, during feedback phase of loss trials of the BART, SA patients had greater activation in the left dorsolateral prefrontal cortex (dlPFC) than NS patients.

CONCLUSION

Taken together, we present novel findings and propose interpretations that the differential insula activation likely relates to high uncertainty-aversion in SA patients, contrary to the typical view that they are impulsive and risk prone. The differential left dlPFC activation likely suggests hypersensitivity to loss, contributing to conservative decision-making at large, and extreme choices such as suicide when value estimations are compromised and emotionally overwhelmed. The interactive interpretation places a renewed focus on psychological pain avoidance as a robust motivator for suicidal behavior.

Multimodal Elements of Suicidality Reduction After Transcranial Magnetic Stimulation

OBJECTIVES

Repetitive transcranial magnetic stimulation (TMS) is a promising treatment for suicidality, but it is underlying neural mechanisms remain poorly understood. Our prior findings indicated that frontostriatal functional connectivity correlates with the severity of suicidal thoughts and behaviors. In this secondary analysis of data from an open label trial, we evaluated whether changes in frontostriatal functional connectivity would accompany suicidality reductions following TMS. We also explored the relationship between frontostriatal connectivity change and underlying white matter (WM) organization.

MATERIALS AND METHODS

We conducted seed-based functional connectivity analysis on participants (N = 25) with comorbid post-traumatic stress disorder and depression who received eight weeks of 5 Hz TMS to left dorsolateral prefrontal cortex. We measured clinical symptoms with the Inventory of Depressive Symptomatology-Self Report (IDS-SR) and the PTSD Checklist for DSM-5 (PCL-5). We derived suicidality from IDS-SR item 18. Magnetic resonance imaging data were collected before TMS, and at treatment end point. These data were entered into analyses of covariance, evaluating the effect of suicidality change across treatment on striatal and thalamic functional connectivity. Changes in other PTSD and depression symptoms were included as covariates and results were corrected for multiple comparisons. Diffusion connectometry in a participant subsample (N = 17) explored the relationship between frontal WM integrity at treatment baseline and subsequent functional connectivity changes correlated with differences in suicidality.

RESULTS

Suicidal ideation decreased in 65% of participants. Reductions in suicidality and functional connectivity between the dorsal striatum and frontopolar cortex were correlated (p-False Discover Rate-corrected < 0.001), after covariance for clinical symptom change. All other results were nonsignificant. Our connectometry results indicated that the integrity of frontostriatal WM may circumscribe functional connectivity response to TMS for suicide.

CONCLUSIONS

Targeted reduction of fronto-striatal connectivity with TMS may be a promising treatment for suicidality. Future research can build on this multimodal approach to advance individualized stimulation approaches in high-risk patients.

Translating Interventional Neuroscience to Suicide: It's About Time

Despite significant advances in psychiatric and psychological treatment over the last 30 years, suicide deaths have increased. Unfortunately, neuroscience insights have yielded few translational interventions that specifically target suicidal thoughts and behaviors. In our view, this is attributable to two factors. The first factor is our limited integration of neurocircuitry models with contemporary suicide theory. The second challenge is inherent to the variable nature of suicide risk over time. Few interventional neuroscience studies evaluate how temporal fluctuations in risk affect treatment, despite evidence that temporality is a key component distinguishing suicide phenotypes. To wit, individual variability in risk trajectories may provide different treatment targets to engage as a patient moves between suicidal ideation and attempt. Here, we first review contemporary ideation-to-action theories of suicide from a neurobiological perspective, focusing on valence and executive function circuits and the key role of state-induced (e.g., within stressful contexts) functional modulation on longitudinal risk trajectories. We then describe neural correlates of suicide reduction following various interventions, ranging from circuit specific (i.e., transcranial magnetic stimulation) to broader pharmacological (i.e., ketamine, lithium) to psychological (i.e., brief cognitive therapy). We then introduce novel strategies for tracking risk in naturalistic settings and real time using ecological momentary interventions. We provide a critical integration of the literature focusing on the intersection between targets and temporality, and we conclude by proposing novel research designs integrating real-time and biologically based interventions to generate novel strategies for future suicide reduction research.

Information Sources, Risk Perception, and Efficacy Appraisal's Prediction of Engagement in Protective Behaviors Against COVID-19 in China: Repeated Cross-sectional Survey

Background

As the COVID-19 pandemic has become a major public health threat worldwide, it is critical to understand what factors affect individual engagement in protective actions. Because of its authoritarian political system and state-owned media system, how Chinese individuals engaged in protective actions against COVID-19 might be different compared to other countries.

Objective

The purpose of this study is to examine how the source of information about COVID-19, Chinese individuals’ risk perception of COVID-19 (ie, perceived severity and perceived susceptibility), and their efficacy appraisal in controlling COVID-19 (ie, response efficacy and self-efficacy) affected their engagement in protective actions. Additionally, this study aims to investigate whether there is any difference in these relationships throughout the duration of this pandemic.

Methods

A six-wave repeated cross-sectional survey (N=1942) was conducted in six major cities in China between February 7 and April 23, 2020. Participants’ reliance on expert versus inexpert sources for information about COVID-19, their perceived severity of and susceptibility to COVID-19, their response efficacy and self-efficacy, and their engagement in protective actions (staying at home, wearing a face mask, and washing hands) were measured. Demographic variables (sex, age, income, education, and city of residence), knowledge of COVID-19, and self-rated health condition were controlled.

Results

Reliance on expert sources did not become the major factor that motivated these actions until wave 3, and the negative effect of inexpert sources on these actions was limited to wave 2. Perceived severity encouraged some protective behaviors but its effect varied depending on the specific behavior. In addition, perceived severity exhibited a stronger effect on these behaviors compared to perceived susceptibility. The positive effect of response efficacy was only significant at waves 1 and 2, and limited to certain behaviors.

Conclusions

Chinese individuals’ engagement in protective behaviors might not entirely be their autonomous decision but a result of compliance with executive orders. After the early outbreak, expert sources started to facilitate protective behaviors, suggesting that it might take time to develop trust in these sources. The facilitating effect of perceived severity lasted throughout the duration of the pandemic, but that of response efficacy was limited to the early stage.

Serious and persistent suicidality among European sexual minority youth

Background

Suicide is a leading cause of death among adolescents and more knowledge from high risk groups is needed in order to develop effective preventive strategies. The aim of this study was to evaluate the association between sexual minority status and suicidality in a multinational sample of European school pupils.

Methods

A self-report questionnaire was delivered to 2046 adolescents (mean age 15.34±1.01; 56.3% females) recruited from 27 randomly selected schools in 6 European countries. Suicidal ideation, measured with the Paykel Suicide Scale (PSS), and lifetime suicide attempts were compared between heterosexual and sexual minority (i.e. those with a non-heterosexual orientation) youth. Poisson regression analyses studied the longitudinal association between sexual minority status and the rate of serious suicidal ideation, measured at three time-points during a 4-month period. Several variables, including alcohol and illegal drugs use, bullying, family interaction, school-related stress, economic status, and religiosity, were included in multivariable analysis. Sex-stratified analyses evaluated the association respectively among females and males.

Results

Of 1958 pupils included in analysis (mean age 15.35±1.00; females 56.8%), 214 (10.9%) were categorized as sexual minority youth (SMY). When compared to heterosexual youth (HSY), SMY were significantly more exposed to substance abuse, bullying, school-related stress, and lower economic status. SMY pupils had significantly higher suicidal ideation scores (p<0.001; r 0.145) as well as higher prevalence of serious suicidal ideation (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.83–3.79) and previous suicide attempts (OR 2.72, 95%CI 1.77–4.18), compared to their HSY peers. The rate of serious suicidal ideation reports during the study was significantly higher among SMY compared to HSY (rate ratio [RR] 2.55, 95%CI 1.90–3.43). A significant difference was found even when controlling for the pupils’ country as well as after adjustment for alcohol and illegal drugs use, bullying, family interaction, school-related stress, economic status, and religiosity (adjusted RR 1.73, 95%CI 1.23–2.48). Stratified analyses showed significant associations between SMY status and persistent serious suicidal ideation for both sexes, with a notably strong association among male pupils (females aRR 1.51, 95%CI 1.01–2.24; males aRR 3.84, 95%CI 1.94–7.59).

Conclusions

European sexual minority youth are a high-risk group for suicidality, independently from objective factors such as victimization or substance abuse. There is a need to develop primary and secondary preventive measures for sexual minority youth, including the management of context vulnerabilities and related distal stressors, before the establishment of proximal stressors. Context-targeting interventions may effectively focus on social and economic factors, as well as on the potentially different risk profile of female and male sexual minority youth.

Association of Loss Aversion, Personality Traits, Depressive, Anxious, and Suicidal Symptoms: Systematic Review

OBJECTIVE

Loss aversion is defined as the individual perception of losses with a more significant impact than the gains of the same proportion, where people would be more sensitive to the possibility of losing objects or money than to the possibility of winning, even the same quantities. However, studies relating to loss aversion and psychological factors are still incipient. The aim of the present literature review was to identify and analyze the results of studies that investigated loss aversion regarding personality traits and symptoms of depression, anxiety, and suicidal tendencies.

METHOD

A systematic review was done through PUBMED and Scopus databases. Descriptors were defined according to each database specificities.

RESULTS

At first, 103 articles were encountered. After evaluation of the inclusion and exclusion criteria, there were a total of 14 remaining articles that were group together into six categories related to loss aversion, depression, anxiety, suicidal tendencies, and personality.

CONCLUSIONS

The present study contributes to the literature mapping in the Behavioural Economics field. However, discrepancies were found among the studies, which made it difficult to acquire more conclusive findings.

Psychological mechanisms of loss aversion: A drift-diffusion decomposition

Decision makers often reject mixed gambles offering equal probabilities of a larger gain and a smaller loss. This important phenomenon, referred to as loss aversion, is typically explained by prospect theory, which proposes that decision makers give losses higher utility weights than gains. In this paper we consider alternative psychological mechanisms capable of explaining loss aversion, such as a fixed utility bias favoring rejection, as well as a bias favoring rejection prior to gamble valuation. We use a drift diffusion model of decision making to conceptually distinguish, formally define, and empirically measure these mechanisms. In two preregistered experiments, we show that the pre-valuation bias provides a very large contribution to model fits, predicts key response time patterns, reflects prior expectations regarding gamble desirability, and can be manipulated independently of the valuation process. Our results indicate that loss aversion is the result of multiple different psychological mechanisms, and that the pre-valuation bias is a fundamental determinant of this well-known behavioral tendency. These results have important implications for how we model behavior in risky choice tasks, and how we interpret its relationship with various psychological, clinical, and neurobiological variables.

Cognitive modelling to assess decision-making impairments in patients with current depression and with/without suicide history

It has been reported that decision making is impaired in suicide attempters. Decision making is a complex process and little is known about its different components. Yet, this information would help to understand the functioning of suicidal minds. In this study, the Prospect Valence-Learning (PVL) computational model was applied to the Iowa Gambling Task (IGT) to investigate and compare decision-making components in patients with affective disorder and with/without history of suicide attempts and in healthy controls. To this aim, 116 inpatients with current major depressive episode (among whom 62 suicide attempters) and 38 healthy controls were recruited. Decision-making performance was measured using the IGT. The Bayesian computational PVL model was applied to compare the feedback sensitivity, loss aversion, learning/memory, and choice consistency components of decision making in the different groups. Depressive symptomatology was assessed using the Beck Depression Inventory short form (BDI-SF). The total IGT net score and the loss aversion and learning/memory scores were lower in suicide attempters than in healthy controls. The choice consistency score was low in all patients (with/without suicide history) compared with healthy controls. Moreover, patients with high BDI score showed a positive relationship between the choice consistency score and suicide attempt. These findings suggest that decision-making impairment in depressed patients with and without suicidal history might be the result of underlying problems in feedback processing and task learning, which influence the building of long-term strategies. All these impairments should be targeted in therapeutic strategies for suicidal patients.

Atypical Cortical Activation During Risky Decision Making in Disruptive Behavior Disordered Youths With Histories of Suicidal Ideation

BACKGROUND

Suicidality is a leading cause of death among adolescents. In addition to other psychiatric conditions, youths with attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (DBDs) are at heightened risk for suicide. Decision-making deficits are a hallmark symptom of ADHD and DBDs and are also implicated in suicidal behavior. We examined behavioral and neural differences in decision making among youths with ADHD and DBDs with (SI+) and without (SI-) histories of suicidal ideation.

METHODS

The Balloon Analog Risk Task, a risky decision-making task, was completed by 57 youths with ADHD and DBDs (38% SI+) during functional magnetic resonance imaging. Mean stop wager (mean wager at which youths bank money) was the primary measure of risk taking. We conducted whole-brain and region-of-interest analyses in the anterior cingulate cortex and orbitofrontal cortex (OFC) during choice (win vs. inflate) and outcome (inflate vs. explode) contrasts using parametric modulators accounting for probability of balloon explosion.

RESULTS

There were no differences between SI+ and SI- youths in Balloon Analog Risk Task performance. SI+ youths showed decreasing activation in the right medial frontal gyrus when choosing inflate as explosion probability increased compared with SI- youths. During explosions, SI- youths showed increasing activation in the left OFC as explosions became more likely. SI+ showed increasing left medial OFC activity in response to inflations as explosion probability increased.

CONCLUSIONS

SI+ youths may show heightened sensitivity to immediate reward and decreased sensitivity to potential loss as evidenced by medial frontal gyrus activity. OFC findings suggest that SI+ youths may be drawn to reward even when there is high probability of loss.

Increased myoinositol in the anterior cingulate cortex of veterans with a history of traumatic brain injury: a proton magnetic resonance spectroscopy study

In this study of veterans, we used a state-of-the-art neuroimaging tool to probe the neurometabolic profile of the anterior cingulate cortex in veterans with traumatic brain injury (TBI). We report significantly elevated myoinositol levels in veterans with TBI compared with those without TBI.

A multi factorial model of self-harm behaviors in Anorexia-nervosa and Bulimia-nervosa

BACKGROUND

Co-existence of eating disorders and NSSI, suicide attempts and ideations is well established yet much is not known about the personality traits and behavioral tendencies that maintain this relationship. To this date no empirical work has been produced that offers a multifactorial view on the contributing variables to the occurrence of self-harm behaviors in EDs.

METHOD

Binge eating, depression, impulsivity, ruminations and loss aversion were assessed in a sample of 93 patients diagnosed with Anorexia-Nervosa and Bulimia-Nervosa and other EDs with a history of NSSI and suicide attempts.

RESULTS

Binge eating was found to be a predictor of depression, which in turn was found to be related to NSSI frequency, suicide attempts and suicide ideations. Ruminations were found to mediate a relationship between depression and suicide ideations. Trait impulsivity predicted suicide attempts, while the attentional construct of impulsivity was associated to suicide ideations as well as attempts. Higher loss aversion was positively associated with NSSI frequency and suicide ideations.

CONCLUSION

Our findings suggest that trait and state aspects of impulsivity are related to different self-harm behaviors in EDs. Exploring these differences is potentially of great value in understanding the process of transition from suicidal ideation to suicide attempt and the process of NSSI and may assist clinicians formulate better interventions for patients with EDs at risk. Ways in which individual findings in our model correspond with previous research and future implications are discussed.

Biological bases of suicidal behaviours: A narrative review

Suicidal behaviour is a multifaceted phenomenon that concerns all human populations. It has been suggested that a complex interaction between the individual genetic profile and environmental factors throughout life underlies the pathophysiology of suicidal behaviour. Although epidemiological and genetic studies suggest the existence of a genetic component, exposure to biological and psychosocial adversities, especially during critical developmental periods, also contributes to altering the biological responses to threat and pleasure. This results in amplified maladaptive cognitive and behavioural traits and states associated with suicidal behaviours. Alterations in the cognitive inhibition and decision-making capacity have been implicated in suicidal behaviours. Structural and functional changes in key brain regions and networks, such as prefrontal cortex, insula and default mode network, may underlie this relationship. Furthermore, the shift from health to suicidal behaviour incorporates complex and dynamic changes in the immune and stress responses, monoaminergic system, gonadal system and neuroplasticity. In this review, we describe the major findings of epidemiological, genetic, neuroanatomical, neuropsychological, immunological and neuroendocrinological studies on suicide behaviours to provide a solid background for future research in this field. This broad overview of the biological bases of suicide should promote neuroscience research on suicidal behaviours. This might lead to improved biological models and to the identification of evidence-based biomarkers, treatment options and preventive strategies.

The Fear of Losing-Nonsuicidal Self-Injury as a Protective Mechanism in Eating Disorders

Background: This study examined the moderating role of loss aversion (LA) on the relationship between impulsivity, nonsuicidal self-injury (NSSI), suicidal attempts, and ideations among Eating Disorder (ED) patients. Methods: Data was collected on 81 ED patients and 37 healthy controls. ED patients were divided into 2 groups: 25 AN-Rs, 56 AN-BPs and BNs. Measurements of trait impulsivity, LA, NSSI, suicide attempts, and suicide ideations were collected. Results: The rate of attempting suicide was highest in the AN-BP/BN (34.8%), lower in the AN-Rs (8%), and the lowest in the controls (2.7%). Suicide ideation was also higher in AN-BP/BN compared to both AN-R and controls. NSSI was higher in the AN-BP/BN group compared to both AN-R and control groups. LA scores were lower among participants with EDs compared to controls. BMI and depression were positively associated with suicide ideation and NSSI. Impulsivity was associated to suicide attempt and suicide ideation. Contrary to our hypothesis, LA scores were positively correlated with NSSI and SI. A stepwise regression revealed that contradictory to our hypothesis, higher LA predicted NSSI prevalence severity of NSSI and suicide ideation. Limitations: (1) Cross-sectional design; (2) Relatively small sample size of clinical subjects and only female participants; (3) Heterogeneity of treatment status. Conclusions: EDs are associated with lower levels of LA compared to general population. Although high LA is considered a protective factor against "high damage" decisions, it may serve as a facilitator of lower risk decisions which help the individual soothe and communicate his or her own suffering such as NSSI.