Cognition and self-injurious thoughts and behaviors: A systematic review of longitudinal studies

Examining the relationship between subtypes of rumination and non-suicidal self-injury: A meta-analytic review

INTRODUCTION

Non-suicidal self-injury (NSSI) is a highly prevalent maladaptive behavior, often used to cope with intense negative affect. Rumination is an emotion regulation strategy that leads to fixation on and exacerbation of (typically) negative affective states. However, studies examining the relationship between rumination and NSSI have yielded mixed results, showing high degrees of heterogeneity.

METHODS

The present study conducted meta-analyses (k = 50) of the association between overall rumination and NSSI, and independent meta-analyses for each of four subtypes of rumination (general, depressive, brooding, reflection rumination). Potential moderators that may influence the magnitude of these relationships were also examined.

RESULTS

A small-to-moderate positive association between rumination and NSSI was found independent of rumination subtype. Moderating effects included NSSI outcome measure and study design for overall rumination and general rumination, respectively. Race was found to moderate the relationships between both brooding and depressive rumination and NSSI, though in inverse directions. An analysis of effect heterogeneity across studies suggested that undetected moderators may be present.

CONCLUSION

Results of this study support the relationships between rumination subtypes and NSSI and identify factors that may impact these relationships. Continued research is needed to understand this association, particularly in more varied subtypes of rumination and cognitive-affective moderators.

Do people know how suicidal they will be? Understanding suicidal prospection

INTRODUCTION

Little research has been done on how people mentally simulate future suicidal thoughts and urges, a process we term suicidal prospection.

METHODS

Participants were 94 adults with recent suicidal thoughts. Participants completed a 42-day real-time monitoring study and then a follow-up survey 28 days later. Each night, participants provided predictions for the severity of their suicidal thoughts the next day and ratings of the severity of suicidal thoughts over the past day. We measured three aspects of suicidal prospection: predicted levels of desire to kill self, urge to kill self, and intent to kill self. We generated prediction errors by subtracting participants' predictions of the severity of their suicidal thoughts from their experienced severity.

RESULTS

Participants tended to overestimate (although the average magnitude was small and the modal error was zero) the severity of their future suicidal thoughts. The best fitting models suggested that participants used both their current suicidal thinking and previous predictions of their suicidal thinking to generate predictions of their future suicidal thinking. Finally, the average severity of predicted future suicidal thoughts predicted the number of days participants thought about suicide during the follow-up period.

CONCLUSIONS

This study highlights prospection as a psychological process to better understand suicidal thoughts and behaviors.

Reliability and validity of the Suicide Cognitions Scale-Revised (SCS-R) in emerging adulthood in Turkey

Suicidal thoughts and behaviors (STBs) are a significant public health problem. This study aims to examine the validity and reliability of the Turkish version of the Suicide Cognitions Scale-Revised (SCS-R). Participants (N = 442, age range: 18-29 years) completed the SCS-R, the Beck Depression Inventory, the Inventory of Statements About Self-injury, the Suicide Probability Scale, and the Suicide Rumination Scale. Principal component analysis showed that the SCS-R consisted of a single factor and that the SCS-R could differentiate between participants at high risk and low risk of suicide. High-to-moderate positive associations were found between the measures of depression, suicide probability, suicide rumination, and non-suicidal self-injury and suicide cognition. The Turkish version of the SCS-R has good psychometric properties. This scale can be used to screen for cognitive patterns that are most prone to suicide and to manage such cognitive characteristics, which are important steps for preventive interventions.

Suicide-related cognitions and emotional bias performance in a community sample

BACKGROUND

Suicide is theorized to be connected to social interactions and feelings of belongingness. Those with suicide-related cognitions (SRCs) demonstrate attentional bias toward negative or suicide-related words, which can lead to increased feelings of rejection or alienation. As social interactions employ both verbal and nonverbal cues, there exists a gap in understanding how perception of emotional expressions can contribute to the development or exacerbation of suicidal ideation.

METHODS

The current sample (N = 114, 60.5 % female, 74.6 % white) completed the Suicide Cognitions Scale-Revised (SCS-R) and Patient Health Questionnaire (PHQ-9) to assess SRCs and depression severity. The Emotional Bias Task (EBT) was used to assess emotional response latency.

RESULTS

Multiple regression analyses on EBT results showed that endorsement of SRCs and depression severity were not associated with any particular emotional response bias. However, presence of SRCs showed an association with longer latencies to identify ambiguous emotional expressions, even when controlling for depressive symptoms and age LIMITATIONS: Measures were self-completed online. Relative homogeneity of the sample and cross-sectional design limits interpretation of the results.

CONCLUSIONS

Those with more severe SRCs take longer to recognize positive, nonverbal cues. Irregular processing of positive emotional stimuli combined with bias toward negative verbal cues could worsen feelings of rejection or alienation in social interactions, therefore increasing risk of developing SI. This suggests that interventions focusing on allocation of attentional resources to process positive social cues may be beneficial for those with SRCs to reduce severity and risk of suicide.

Sleep disturbance and suicidal ideation mediated by psychotic-like experiences in adolescents: a two-wave longitudinal study

STUDY OBJECTIVES

Sleep disturbance may cause suicidal ideation (SI). This study aimed to examine their co-occurrence rate among adolescents and investigate whether psychotic-like experiences (PLEs) mediate this association.

METHODS

A total of 17 722 Chinese adolescents were included in this two-wave longitudinal study. The baseline survey (time 1, T1) was conducted between April 21 and May 12, 2021, and the follow-up survey (time 2, T2) was implemented between December 17 and 26, 2021. At T1, participants completed questionnaires to assess their sleep disturbance, sleep duration, PLEs, SI, depressive symptoms, and sociodemographic characteristics. At T2, participants reported their PLEs, SI, and negative life events.

RESULTS

The SI prevalence decreased from 20.2% (T1) to 18.4% (T2). Participants with SI showed significantly higher prevalence of sleep disturbance and short sleep duration compared to those without SI. Baseline sleep disturbance and short sleep duration were both associated with the increased risk of SI 6 months later. These longitudinal links were mediated by PLEs, independent of baseline covariates and negative life events.

CONCLUSIONS

These findings provide a novel insight into the mechanism linking sleep problems and suicidality, and stress the significance of assessing and addressing sleep problems and PLEs for adolescent suicide prevention and intervention.

Depression and posttraumatic stress disorder in adolescents with nonsuicidal self-injury: comparisons of the psychological correlates and suicidal presentations across diagnostic subgroups

BACKGROUND

Nonsuicidal self-injury (NSSI) combined with suicide ideation increases the risk of suicidal behaviors. Depression and posttraumatic stress disorder (PTSD) are comorbidities of NSSI compounding this relationship. The present study compared diagnostic subgroups of NSSI based on current depression and PTSD on psychological correlates (i.e., vulnerabilities and impairment) and suicidal presentations (i.e., suicidal cognitions and behaviors) in a psychiatric sample of adolescents.

METHODS

Eighty-seven adolescents meeting DSM-5 criteria for NSSI and 104 age-range-matched nonclinical controls (NC) participated. Participants completed self-report measures on psychological vulnerabilities and impairment (e.g., emotion regulation difficulties, negative cognitions). Adolescents with NSSI also completed clinical interviews on psychiatric diagnoses and a recent self-injurious behavior (SIB). Scores on the psychological correlates of NSSI were compared between adolescents with NSSI and NC, and across three diagnostic subgroups of NSSI (A: NSSI+/depression-/PTSD-, n = 14; B: NSSI+/depression+/PTSD-, n = 57; C: NSSI+/depression+/PTSD+, n = 14). Differences between NSSI diagnostic subgroups were tested on the motives for SIB and accompanying suicidal presentations (e.g., desire, intent, motive, lethality).

RESULTS

Common comorbidities of NSSI included depression, panic disorder, generalized anxiety disorder, and PTSD. The NSSI subgroup classification was significantly associated with panic disorder, which was controlled for in the subsequent group comparisons. Overall, adolescents who engage in NSSI with vs. without depression reported more psychological vulnerabilities and impairment and a greater degree of suicidal thoughts/desire in SIB (i.e., groups B, C >A), which remained significant after controlling for panic disorder. An increased odds of the suicidal motive for SIB was found in adolescents with all three conditions (i.e., group C: NSSI+/depression+/PTSD+) compared to those with NSSI but neither depression nor PTSD (i.e., group A: NSSI+/depression-/PTSD-); however, this was not significant after controlling for panic disorder.

CONCLUSIONS

Psychological underpinnings of adolescent NSSI in clinical contexts may be largely associated with concurrent depression. Suicidal motives in adolescents who engage in NSSI in the presence of depression and PTSD may be confounded by the co-occurrence of panic disorder. This study warrants the importance of attending to the comorbid depression with NSSI in adolescents as it is related to an increase in suicidal desire accompanying SIB.

The relationship between major life events and non-suicidal self-injury among college students: the effect of rumination and body image

Background

Non-suicidal self-injury (NSSI) poses a growing risk to public health worldwide. While numerous studies have identified major life events as key risk factors for NSSI, the mechanisms by which emotional and cognitive problems mediate or moderate this relationship remain unclear. To enhance the understanding of this field, we will draw upon the cascade theory of self-injury and the benefits and barriers model, to examine the relationship between major life events and NSSI, as well as the effect of rumination and body image.

Methods

A sample of 2,717 college students (Mage = 19.81 years; SD = 1.09) participated in this study and anonymously completed the questionnaires. The moderated mediation model were conducted using Model 4 and Model 15 of the Process macro program in SPSS.

Results

The results showed that rumination mediated the positive relationship between major life events and NSSI. Furthermore, body image was found to moderate both the relationship between major life events and NSSI, as well as the relationship between rumination and NSSI.

Conclusion

The current findings suggest that rumination is an important mediator in the relationship between major life events and NSSI among college students. Teachers, parents, and researchers should recognize the important role of body image self-perceptions of college students and actively promote a healthy and accurate body image.

Facets of Suicidal Ideation

According to SAMHSA (2023), approximately 16,600,000 American adults and teens reported having serious thoughts of suicide in 2022. While suicide prevention has primarily focused on suicide deaths and attempts, we contend that suicidal ideation (SI) deserves more in-depth investigation and should be an essential intervention target on its own. In support of this point, we provide three examples of ways to improve specificity in understanding of SI through the study of controllability of SI, the language used to assess SI, and measuring SI in real time. We also consider qualitative work on the content of SI, its treatment, and definitional considerations. We thus call for an increased general focus on SI within research, clinical care, and policy.

Gender and Age Influence on Emergency Department Visits for Non-Suicidal Self-Injuries in School Aged Children in Italy: An 11 Years Retrospective Cross-Sectional Study

Objectives: Non-suicidal self-injury (NSSI) poses a threat in developmental ages, yet there is a scarcity of studies on NSSI trends, especially those in emergency departments (ED). Methods: The aim of this cross-sectional study is to describe trends in ED visits for NSSI among young people aged between 5 and 19 years in Italy from 2011 to 2021 in Piedmont. From the ministerial ED discharge information system, all occurring NSSIs were identified by medical report and/or ICD9CM code and reported as a population rate and a visit rate on all ED requests. Results: The general rate of ED visits remained stable, with around 210,000 (55% males) visits each year, along the whole period from 2011 to 2019, then halved during 2020 and 2021. The NSSI population and visits rates increased from 2013, peaking in 2019 at a rate of around 25 and 23 NSSI visits (girls) and 76 and 69 NSSI (boys) per 100,000 ED visits. In 2020 and 2021, the rate of NSSI visits increased, particularly in girls and among older adolescents. Conclusion: The gradual increase of NSSI over the last decade is a rising public health issue, which deserves wider attention to ensure early detection and prevention.

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.

Cognitive inflexibility and suicidal ideation among adolescents following hospitalization: The moderating role of life stress

BACKGROUND

Cognitive inflexibility has recently been investigated as potential vulnerability factor for suicidal ideation (SI), but the context in which it may convey risk is unclear. Life stress has also been reliably associated with SI among adolescents, and following a stress-diathesis model, may be a factor that moderates the relationship between cognitive inflexibility and SI.

METHODS

Psychiatrically hospitalized adolescents (N = 259) at high risk for future SI were followed for 18 months after discharge. Interviews assessing life stress and SI and a neurocognitive task assessing cognitive inflexibility were conducted at six- and 12-months. SI was also assessed at 18-month post-discharge. Linear mixed models were used to determine the moderating effect of stress on the relationship between cognitive inflexibility and SI, accounting for relevant clinical and demographic covariates.

RESULTS

Chronic stress moderated the association between cognitive inflexibility and SI, with a stronger association found among youth with greater levels compared to lower levels of chronic stress. This finding was maintained after statistically adjusting for depressive symptoms and relevant demographic covariates. No prospective associations between cognitive inflexibility, life stress, and SI were found.

LIMITATIONS

SI was measured at 6-month intervals, precluding evaluation of the relationship on a more proximal timescale.

CONCLUSIONS

Cognitively inflexible adolescents under conditions of high chronic stress are more likely to experience increased SI severity, supporting a cognitive inflexibility stress-diathesis model of SI in adolescents. The findings highlight the importance of assessing these modifiable factors among adolescents at a high risk for SI.

Executive functions in non-suicidal self-injury comorbid first-episode and drug-naïve depression among adolescents

Executive functions(EFs) may be associated with the emergence of non-suicidal self-injury(NSSI) due to their role as behavior controllers. EFs includes three core cognitive processes: inhibitory control, working memory, and cognitive flexibility(i.e. the ability to selectively alter cognitive strategies to generate appropriate behavior in the changing environment). This study aimed to systematically explore the three core EFs in depressed adolescents with NSSI. The data was obtained from the baseline data of the Chinese adolescent depression Cohort. The adolescents underwent cognitive assessments to yield domain-specific scores in EFs using the Digit Span Backward test(DSB), the Stroop Color-word interference test- color-word condition(Stroop-CW), and the Wisconsin Card Sorting tests(WCST). The significant differences in WCST scores were found between the NSSI group and the non-NSSI group. NSSI frequency was moderately positively correlated with total errors and negatively correlated with the number of categories completed. The number of categories completed in the "≥200″ NSSI frequency group was significantly lower than that in the "≤10″ NSSI group. The current findings suggested that depressed adolescents who had engaged in NSSI have poorer cognitive flexibility performance compared to adolescents without NSSI. As the frequency of NSSI increased, cognitive flexibility might become worse. These results provide evidence of a connection between executive dysfunctions and NSSI in depressed adolescents.

Qualitative analysis of the cognitive triad in a sample of the general population in response to the COVID-19 pandemic

This paper explored cognitive responses to the COVID-19 pandemic in those selfreporting depressive symptoms during a period of realistic health, economic and social threat. Negative cognitions are a key therapy target for evidence-based psychological interventions. A cross-sectional survey was conducted with a convenience sample from the general population between December 2020 and February 2021. Adult respondents (n = 555) completed open text-box questions which provided prompts of the cognitive triad: "I am…/I am not…"; "Other people are…/Other people are not…"; "The world is…". These qualitative data were analysed using reflexive thematic analysis. Thematic responses were compared between people who self-reported moderate depressive symptoms (n = 223) and those who did not (n = 332). Fourteen independent themes were identified. Those self-reporting depressive symptoms described significantly fewer positive cognitions across all three aspects of the cognitive triad, X2 = 60.40 p < 0.01;  X2 = 10.51 p < 0.05; X2 = 12.22 p < 0.01. Those self-reporting depressive symptoms also reported more self-referent negative cognitions. These data highlighted that an absence of positive cognitions differentiated the two groups more greatly than negative cognitions. These data have implications for the cognitive targets in psychological therapies in realistic high-stress situations. This paper explored cognitive responses to the COVID-19 pandemic in those selfreporting depressive symptoms during a period of realistic health, economic and social threat. Negative cognitions are a key therapy target for evidence-based psychological interventions. A cross-sectional survey was conducted with a convenience sample from the general population between December 2020 and February 2021. Adult respondents (n = 555) completed open text-box questions which provided prompts of the cognitive triad: "I am…/I am not…"; "Other people are…/Other people are not…"; "The world is…". These qualitative data were analysed using reflexive thematic analysis. Thematic responses were compared between people who self-reported moderate depressive symptoms (n = 223) and those who did not (n = 332). Fourteen independent themes were identified. Those self-reporting depressive symptoms described significantly fewer positive cognitions across all three aspects of the cognitive triad, X2 = 60.40 p < 0.01;  X2 = 10.51 p < 0.05; X2 = 12.22 p < 0.01. Those self-reporting depressive symptoms also reported more self-referent negative cognitions. These data highlighted that an absence of positive cognitions differentiated the two groups more greatly than negative cognitions. These data have implications for the cognitive targets in psychological therapies in realistic high-stress situations.

The Perspectives of Health Care Providers on Adolescent Non-Suicidal Self-Injury

OBJECTIVE

This study examined the perspectives and strategies of care providers when managing adolescent non-suicidal self-injury in residential and acute inpatient units throughout the Midwest region. NSSI frequency, intensity, duration, onset, method, location, and interventions were examined, among other topics including care provider attitudes, service delivery type, ways to reduce NSSI behaviors, and whether any NSSI-specific interventions are used in psychiatric settings.

METHOD

Surveys were disseminated to nurses, practitioners, and clinicians at psychiatric hospitals in the Midwest region. All questions used free text responses and were developed from the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT), the SOARS Model, and Clinician-Rated Severity of Non-suicidal Self-Injury Scale.

RESULTS

The findings underscored the high incidence of NSSI among adolescent patients, highlighting the urgent need for creating hospital trainings and best practices for NSSI, among other topics such as routine physical check-ins and enhanced NSSI-specific interventions.

CONCLUSION

There is a concerning gap in the number of NSSI-specific interventions used by care providers in psychiatric inpatient facilities in the Midwest region of the United States. The need for targeted treatment, training, and programming for adolescent NSSI is essential.

Issues and opportunities of digital phenotyping: ecological momentary assessment and behavioral sensing in protecting the young from suicide

Digital phenotyping refers to the collection of real-time biometric and personal data on digital tools, mainly smartphones, and wearables, to measure behaviors and variables that can be used as a proxy for complex psychophysiological conditions. Digital phenotyping might be used for diagnosis, clinical assessment, predicting changes and trajectories in psychological clinical conditions, and delivering tailored interventions according to individual real-time data. Recent works pointed out the possibility of using such an approach in the field of suicide risk in high-suicide-risk patients. Among the possible targets of such interventions, adolescence might be a population of interest, since they display higher odds of committing suicide and impulsive behaviors. The present work systematizes the available evidence of the data that might be used for digital phenotyping in the field of adolescent suicide and provides insight into possible personalized approaches for monitoring and treating suicidal risk or predicting risk trajectories. Specifically, the authors first define the field of digital phenotyping and its features, secondly, they organize the available literature to gather all the digital indexes (active and passive data) that can provide reliable information on the increase in the suicidal odds, lastly, they discuss the challenges and future directions of such an approach, together with its ethical implications.

Longitudinal associations between executive function impairments and suicide risk in patients with major depressive disorder: A 1-year follow-up study

Impaired executive function (EF) is a key feature of patients with major depressive disorder (MDD) that several studies have linked to suicidal ideation and suicide attempts. This is the first longitudinal study to examine the association between impaired EF and suicide risk in adult patients with MDD. Longitudinal prospective study with 3 assessment points: baseline, 6 and 12 months. The Columbia-Suicide Severity Rating Scale (C-SSRS) was used to assess suicidality. The Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to assess EF. The association between EF impairments and suicidality was analyzed using mixed-effects models. Out of 167 eligible outpatients, 104 were included in the study. Of these, 72 were re-evaluated at 6 months and 60 at 12 months, obtaining 225 complete observations of the EF. Impaired decision-making and risk-taking behavior were associated with suicidal ideation. Difficulty in impulse control was related to suicidal ideation and to greater severity of suicidal ideation. Impaired spatial planning and working memory was linked to suicide attempts. Our results add to previous literature that the association between EF impairments and suicidality is maintained over the long term, supporting it as a longitudinal risk factor and a possible neurocognitive marker of suicide in patients with MDD.

Non-Invasive Prenatal Testing for "Non-Medical" Traits: Ensuring Consistency in Ethical Decision-Making

The scope of noninvasive prenatal testing (NIPT) could expand in the future to include detailed analysis of the fetal genome. This will allow for the testing for virtually any trait with a genetic contribution, including "non-medical" traits. Here we discuss the potential use of NIPT for these traits. We outline a scenario which highlights possible inconsistencies with ethical decision-making. We then discuss the case against permitting these uses. The objections include practical problems; increasing inequities; increasing the burden of choice; negative impacts on the child, family, and society; and issues with implementation. We then outline the case for permitting the use of NIPT for these traits. These include arguments for reproductive liberty and autonomy; questioning the labeling of traits as "non-medical"; and the principle of procreative beneficence. This summary of the case for and against can serve as a basis for the development of a consistent and coherent ethical framework.

Minority stress, repetitive negative thinking, and internalizing symptoms in sexual minorites: Does cognitive content matter?

BACKGROUND

The Psychological Mediation Framework theorizes that repetitive negative thinking (RNT) mediates the relationship between minority stress and mental health, and this theory has been consistently supported by previous research. Yet, it is unclear whether the process or content of RNT is more important in the development of internalizing symptoms in sexual minorities. Consequently, the goal of the current study was to use structural equation modeling to determine whether there are significant indirect effects of repetitive negative thought content in the relationship between minority stress and internalizing psychopathology.

METHODS

Measures of RNT, internalizing symptoms, and proximal minority stress were completed online by 205 cisgender sexual minority adults. Structural equation modeling was used to examine indirect effects of proximal stress on internalizing symptoms through content-independent RNT, depressive rumination, and sexual orientation-related rumination.

RESULTS

Significant direct effects of proximal minority stress on internalizing symptoms were observed. Indirect effects of proximal stress on internalizing symptoms were observed for content-independent RNT and depressive rumination, but not sexual orientation-related rumination.

CONCLUSIONS

The current study provides evidence that the process and affective valence of RNT contributes more to internalizing symptoms in sexual minorities when compared with sexual orientation-related content. Theoretical and clinical implications are discussed.

For Better or Worse?: The role of cognitive flexibility in the association between nonsuicidal self-injury and suicide attempt

Nonsuicidal self-injury (NSSI) has been repeatedly associated with increased suicide risk. However, the transition from NSSI to suicidal thoughts and behaviors still remains as an enigma. One possible construct that may influence this relationship is cognitive flexibility, which refers to the ability to adapt responses/strategies based on environmental feedback. It may be that greater cognitive flexibility increases one's cognitive accessibility to suicide, making it a more viable option upon distress especially for those with a prior history of NSSI. Conversely, it may be that less cognitive flexibility creates a negative bias that exacerbates the effects of NSSI on suicide. Thus, in this study, we examined how NSSI characteristics (i.e., frequency and methods) interact with cognitive flexibility to predict lifetime suicide attempt (SA) history. Participants were 505 individuals with a lifetime history of NSSI who completed a survey assessing for their NSSI experiences, cognitive flexibility, and SA history. Moderation analyses were conducted while controlling for sexual orientation, which significantly predicted SA history. Results indicated a significant interaction between number of NSSI methods endorsed and cognitive flexibility. In particular, individuals were more likely to have had a history of SA if they scored higher on the alternative subscale of cognitive flexibility. The results suggest that the adaptive value of cognitive flexibility may be context dependent, and highlight the importance of personalized care among those who engage in self-harm.

The Link between Sleep Insufficiency and Self-Injury among In-School Adolescents: Findings from a Cross-Sectional Survey of Multi-Type Schools in Huangpu District of Shanghai, China

Both insufficient sleep and self-injury are rising public health issues among middle school students. Understanding their relationship may guide the intervention and policy making to help youths gain a healthy life. Thus, we analysed the data collected from the Shanghai Students Health Risk Behavior Surveillance (2015) in the Huangpu District. Self-injury was self-reported and categorized into ever or never. Sleep duration was classified as sufficient and insufficient according to the Health China 2030 Plan and the National Sleep Foundation's updated sleep duration recommendations. Crude OR and adjusted OR of sleep duration and covariates were estimated for self-injury using the logistic regression models with standard error clustered on school types. Results showed that 8.42% of the participants had conducted self-injury, with girls more than boys and ordinary school students more than key school students. After full adjustment, sleep insufficiency increased the odds of conducting self-injury by approximately two folds (AOR = 2.08, 95%CI = 1.40-3.07). The odds of self-injury were higher among students studying at ordinary schools (AOR = 3.58, 95%CI = 1.25-10.27) or vocational schools (AOR = 2.00, 95%CI = 1.77-2.26), with comparison to those at key schools. Interventions seeking to solve insufficient sleep need to be multifaceted, with consideration of changing the school environment and multiple social contexts, which create stressful burdens for adolescents' development.

Behavioral measures of impulsivity and compulsivity in adolescents with nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is prevalent among adolescents and research is needed to clarify the mechanisms which contribute to the behavior. Here, the authors relate behavioral neurocognitive measures of impulsivity and compulsivity to repetitive and sporadic NSSI in a community sample of adolescents.

METHODS

Computerized laboratory tasks (Affective Go/No-Go, Cambridge Gambling Task, and Probabilistic Reversal Task) were used to evaluate cognitive performance. Participants were adolescents aged 15 to 17 with (n = 50) and without (n = 190) NSSI history, sampled from the ROOTS project which recruited adolescents from secondary schools in Cambridgeshire, UK. NSSI was categorized as sporadic (1-3 instances per year) or repetitive (4 or more instances per year). Analyses were carried out in a series of linear and negative binomial regressions, controlling for age, gender, intelligence, and recent depressive symptoms.

RESULTS

Adolescents with lifetime NSSI, and repetitive NSSI specifically, made significantly more perseverative errors on the Probabilistic Reversal Task and exhibited significantly lower quality of decision making on the Cambridge Gambling Task compared to no-NSSI controls. Those with sporadic NSSI did not significantly differ from no-NSSI controls on task performance. NSSI was not associated with behavioral measures of impulsivity.

CONCLUSIONS

Repetitive NSSI is associated with increased behavioral compulsivity and disadvantageous decision making, but not with behavioral impulsivity. Future research should continue to investigate how neurocognitive phenotypes contribute to the onset and maintenance of NSSI, and determine whether compulsivity and addictive features of NSSI are potential targets for treatment.

Psychobiological foundations of coping and emotion regulation: Links to maltreatment and depression in a racially diverse, economically disadvantaged sample of adolescent girls

Adolescent risk for depression and passive or active suicidal ideation (PASI) involves disturbance across multiple systems (e.g., arousal regulatory, affective valence, neurocognitive). Exposure to maltreatment while growing up as a child or teenager may potentiate this risk by noxiously impacting these systems. However, research exploring how coordinated disturbance across these systems (i.e., profiles) might be uniquely linked to depressogenic function, and how past maltreatment contributes to such disturbance, is lacking. Utilizing a racially diverse, economically disadvantaged sample of adolescent girls, this person-centered study identified psychobiological profiles and linked them to maltreatment histories, as well as current depressive symptoms and PASI. Girls (N = 237, Mage=13.98, SD=0.85) who were non-depressed/non-maltreated (15.1%), depressed/non-maltreated (40.5%), or depressed/maltreated (44.4%) provided morning saliva samples, completed questionnaires, a clinical interview, and a neurocognitive battery. Latent profile analysis of girls' morning cortisol:C-reactive protein ratio, positive and negative affect levels, and attentional set-shifting ability revealed four profiles. Relative to Normative (66.6%), girls exhibiting a Pro-inflammatory Affective Disturbance (13.1%), Severe Affective Disturbance (10.1%), or Hypercortisol Affective Neurocognitive Disturbance (n = 24, 10.1%) profile reported exposure to a greater number of maltreatment subtypes while growing up. Girls exhibiting these dysregulated profiles were also more likely (relative to Normative) to report current depressive symptoms (all three profiles) and PASI (only Pro-inflammatory Affective Disturbance and Hypercortisol Affective Neurocognitive Disturbance). Of note, girls' cognitive reappraisal utilization moderated profile membership-depression linkages (depressive symptoms, but not PASI). A synthesis of the findings is presented alongside implications for person-centered tailoring of intervention efforts.

Neurocognitive functioning in adolescents with non-suicidal self-injury

BACKGROUND

Non-suicidal self-injury (NSSI) is a highly prevalent transdiagnostic psychiatric symptom in adolescents. Research in adults has begun to investigate neurocognitive processes associated with NSSI as potential underlying phenotypes. However, research on neurocognitive function in adolescent patients with NSSI is scarce.

METHODS

In this study, we examined neurocognitive functioning in the domains of processing speed, attention, learning, working memory, and executive function in a relatively large sample of n = 240 adolescent patients engaging in NSSI and n = 49 healthy controls. Further, associations between neurocognitive performance and clinical characteristics in the patient group were examined.

RESULTS

While conventional regression analyses showed somewhat weaker neurocognition in the NSSI group in several domains, propensity score matching for IQ showed little evidence that patients engaging in NSSI showed worse neurocognition when general intelligence was considered. Further, a random forest machine learning algorithm was not able to classify NSSI vs. control groups based on neurocognitive features. Within the patient group, linear regression and latent class analyses yielded little evidence that neurocognitive performance was related with clinical characteristics or phenotypes.

LIMITATIONS

As the study did not include a clinical control group, findings might not be specific to NSSI.

CONCLUSIONS

Our findings challenge the importance of specific neurocognitive measures related to the presence or severity of NSSI in adolescents. Future studies should consider general intelligence as an important confounding factor and should focus on domains of affective cognition. Finally, longitudinal studies are needed to determine whether low neurocognitive performance serves to inform prognosis of NSSI or psychopathology in general.

Pain avoidance and functional connectivity between insula and amygdala identifies suicidal attempters in patients with major depressive disorder using machine learning

Pain avoidance can effectively classify suicide attempters from non-attempters among patients with major depressive disorder (MDD). However, the neural circuits underlying pain processing in suicide attempters have not been described comprehensively. In Study 1, we recruited MDD patients with a history of suicide attempts (MDD-SA), and those without (MDD-NSA) to examine the patterns of psychological pain using the latent profile analysis. Further, in Study 2, participants including the MDD-SA, MDD-NSA, and healthy controls underwent resting-state functional magnetic resonance imaging. We used machine learning that included features of gray matter volume (GMV), the functional connectivity (FC) brain patterns of the region of interest, and behavioral data to identify suicide attempters. The results identified three latent classes of psychological pain in MDD patients: the low pain class (18.9%), the painful feeling class (37.2%), and the pain avoidance class (43.9%). Furthermore, the proportion of suicide attempters with high pain avoidance was the highest. The accuracy of multimodality classifiers (63%-92%) was significantly higher than that of brain-only classifiers (56%-85%) and behavior-only classifiers (64%-73%). Pain avoidance ranked first in the optimal feature set of the suicide attempt classification model. The crucial brain imaging features were FC between the left amygdala and right insula, right orbitofrontal and left thalamus, left anterior cingulate cortex and left insula, right orbitofrontal, amygdala, and the GMV of right thalamus. Additionally, the optimal feature set, including pain avoidance and crucial brain patterns of psychological pain neural circuits, was provided for the identification of suicide attempters.

Examining multiple features of episodic future thinking and episodic memory among suicidal adults

BCKGROUND

Theories of suicide suggest that suicidal ideation (SI) results in part from difficulty imagining the future, which itself relies on the ability to remember the past. The present study examines multiple components of episodic future thinking and memory including event richness, which is commonly measured within the cognitive literature but has not previously been assessed with suicidal individuals.

METHODS

Here, we tested the associations between SI and episodic future thinking and episodic memory across two studies (Study 1, n = 25; Study 2, n = 141): the first with a healthy comparison group and the second with a psychiatric comparison group.

RESULTS

Future event richness yielded large but statistically non-significant deficits in the SI group relative to healthy controls in Study 1 after controling the false discovery rate. The most robust effects for future thinking emerged in the case of perceived duration of future events, such that the SI group (vs. psychiatric comparison) imagined future events as longer-lasting in Study 2. Across both studies, episodic memory was unrelated to SI, and neither episodic future thinking nor memory predicted future SI.

CONCLUSION

Episodic future thinking may better distinguish individuals with SI history from psychiatric controls when compared with episodic memory, but that this effect is limited to select components of future thinking.

Dynamic Regulatory Processes in the Transition from Suicidal Ideation to Action in Adults Leaving Inpatient Psychiatric Care: An Intensive Longitudinal Study Protocol (Preprint)

Background

US suicide rates have risen steadily in the past decade, and suicide risk is especially high in the months after discharge from inpatient psychiatric treatment. However, suicide research has lagged in examining dynamic within-person processes that contribute to risk over time among individuals known to be at high risk of suicide. Almost no research has examined how affective, cognitive, and physiological processes change over minutes, hours, or days to confer risk of suicidal behavior in daily life.

Objective

This protocol describes a longitudinal study designed to examine real-world changes in risk of suicide across multiple assessment domains. Specifically, the study involves following adults known to be at high risk of suicide after discharge from inpatient psychiatric care using self-report, interview, actigraphy, and behavioral methods to identify proximal contributors to suicidal thoughts and behaviors. First, we hypothesize that negative affective experiences, which are featured in most major suicide theories, will comprise a latent factor indicative of psychache (emotional pain), which will predict increases in suicidal thinking over time. Second, we hypothesize that poor inhibitory control in the context of negative affective stimuli, as well as emotion-related impulsivity, will predict the transition from suicidal thinking to suicidal behavior over time. Third, we hypothesize that short sleep duration will precede within-person increases in suicidal ideation as well as increased odds of suicidal behavior among those reporting suicidal thoughts.

Methods

The desired sample size is 130 adults with past-week suicidal thoughts or behaviors who are receiving inpatient psychiatric treatment. Participants will complete a battery of measures while on the inpatient unit to assess negative affective experiences, emotion-related impulsivity, inhibitory control, typical sleep patterns, and relevant covariates. After discharge from inpatient care, participants will complete 4 weeks of signal-contingent ecological momentary assessment surveys, as well as mobile behavioral measures of inhibitory control, while wearing an actigraphy device that will gather objective data on sleep. Participants will complete interviews regarding suicidal thoughts and behaviors at 4 and 8 weeks after discharge.

Results

The study was funded by the National Institutes of Health in November 2020. Recruitment began in April 2021. Data analysis will begin after completion of data collection.

Conclusions

This study will elucidate how affective, cognitive, and physiological risk factors contribute (or do not contribute) to within-person fluctuations in suicide risk in daily life, with important implications for extant theories of suicide. Of import, the examined risk factors are all modifiable; thus, the results will inform identification of key targets for just-in-time, flexible, personalized, digital interventions that can be used to decrease emotional distress and prevent suicide among those at highest risk.

International Registered Report Identifier (IRRID)

DERR1-10.2196/38582

Implicit Cognition Tests for the Assessment of Suicide Risk: a Systematic Review

PURPOSE OF REVIEW

Suicide risk assessment is a challenge in clinical practice. Implicit measures may present with advantages with respect to explicit methods, and therefore may be useful for the assessment of suicide risk. We conducted a systematic review of 2 databases (PubMed and EMBASE) about implicit tests that measure suicide risk to explore their validity and reliability.

RECENT FINDINGS

Initial research revealed 321 articles. After the selection process, 31 articles were included in the review. The most death-related implicit cognition test used was the Death/Suicide Implicit association test (D/S IAT), followed by the Suicide Stroop Task. The Suicide Affect Misattribution Procedure (S-AMP) and the Death version of the Implicit Relational Assessment Procedure (D-IRAP) were also used. We found that the measures reviewed were generally valid for the assessment of past and future suicidal thoughts and behaviors, with statistically significant results regarding retrospective and prospective associations.

A qualitative systematic review of neurocognition in suicide ideators and attempters: Implications for cognitive-based psychotherapeutic interventions

BACKGROUND

Growing evidence suggests cognitive deficits may represent neurocognitive markers with predictive utility in identifying those at risk for suicide. Characterizing these deficits may offer the opportunity to develop targeted interventions.

AIM

The aim of this systematic qualitative review is to provide a synthesis of the published data on neurocognition in suicide ideators and attempters in order to clarify which neurocognitive targets may be most relevant to address using cognitive-based psychotherapeutic strategies in patients at risk for suicide.

RESULTS

A total of 63 studies met criteria for inclusion. The most consistent findings were in depressed suicide attempters, where deficits in executive subdomains of inhibition, selective attention and decision-making, as well as in working memory, were identified. In contrast, no clear pattern of neurocognitive deficits emerged from studies in suicide ideators across diagnoses.

CONCLUSIONS

More studies are needed to clarify the role of cognitive deficits in specific subtypes of individuals at risk for suicide. The findings are discussed in the context of promising research on cognitive remediation and other psychological interventions.

Conceptualizing death: How do suicidal adolescents view the end of their lives?

OBJECTIVE

Adolescence marks an important time to detect suicide risk, as suicidal ideation often emerges during this developmental period. Death-themed cognitions represent a promising domain of risk factors for suicidal ideation, but they have been understudied among adolescents. To address this knowledge gap, the present study examines the association between adolescents' attitudes and beliefs about death, hereafter referred to as death conceptualizations, and suicidal ideation.

METHODS

Seventy-four adolescents (12-19 years) completed a self-report measure assessing three types of death conceptualizations: Death Avoidance (i.e., suppression of death-related thoughts), Neutral Acceptance (i.e., belief that death is a natural part of life), and Escape Acceptance (i.e., belief that death is a viable escape from pain). Suicidal ideation was assessed at baseline, as well as 3 and 6 months later.

RESULTS

At baseline, suicidal adolescents endorsed higher Escape Acceptance and lower Death Avoidance. Suicidal and nonsuicidal adolescents did not differ in their degree of Neutral Acceptance. Death conceptualizations, especially Escape Acceptance, also predicted future suicidal ideation.

CONCLUSIONS

Initial findings suggest that suicidal adolescents are more likely to believe that death is a viable escape from pain and that this death-related cognition is a risk factor for suicidal ideation.

Emotional response inhibition to self-harm stimuli interacts with momentary negative affect to predict nonsuicidal self-injury urges

The current study investigated whether impaired emotional response inhibition to self-harm stimuli is a risk factor for real-time nonsuicidal self-injury (NSSI) urges. Participants were 60 university students with a history of repetitive NSSI. At baseline, participants completed an emotional stop-signal task assessing response inhibition to self-harm stimuli. Participants subsequently completed an ecological momentary assessment protocol in which they reported negative affect, urgency, and NSSI urge intensity three times daily over a ten-day period. Impaired emotional response inhibition to self-harm stimuli did not evidence a main effect on the strength of momentary NSSI urges. However, emotional response inhibition to self-harm images interacted with momentary negative affect to predict the strength of real-time NSSI urges, after adjusting for emotional response inhibition to neutral images. Our findings suggest that emotional response inhibition deficits specifically to self-harm stimuli may pose vulnerability for increased NSSI urge intensity during real-time, state-level negative affect.

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.

Predicting self-injurious thoughts in daily life using ambulatory assessment of state cognition

Self-injurious thoughts (SITs) fluctuate considerably from moment to moment. As such, "static" and temporally stable predictors (e.g., demographic variables, prior history) are suboptimal in predicting imminent SITs. This concern is particularly true for "online" cognitive abilities, which are important for understanding SITs, but are typically measured using tests selected for temporal stability. Advances in ambulatory assessments (i.e., real-time assessment in a naturalistic environment) allow for measuring cognition with improved temporal resolution. The present study measured relationships between "state" cognitive performance, measured using an ambulatory-based Trail Making Test, and SITs. Self-reported state hope and social connectedness was also measured. Data were collected using a specially designed mobile application (administered 4x/week up to 28 days) in substance use inpatients (N = 99). Consistent with prior literature, state hope and social connectedness was significantly associated with state SITs. Importantly, poorer state cognitive performance also significantly predicted state SITs, independent of hallmark static and state self-report risk variables. These findings highlight the potential importance of "online" cognition to predict SITs. Ambulatory recording reflects an efficient, sensitive, and ecological valid methodology for evaluating subjective and objectives predictors of imminent SITs.

Search for solutions, learning, simulation, and choice processes in suicidal behavior

Suicide may be viewed as an unfortunate outcome of failures in decision processes. Such failures occur when the demands of a crisis exceed a person's capacity to (i) search for options, (ii) learn and simulate possible futures, and (iii) make advantageous value‐based choices. Can individual‐level decision deficits and biases drive the progression of the suicidal crisis? Our overview of the evidence on this question is informed by clinical theory and grounded in reinforcement learning and behavioral economics. Cohort and case–control studies provide strong evidence that limited cognitive capacity and particularly impaired cognitive control are associated with suicidal behavior, imposing cognitive constraints on decision‐making. We conceptualize suicidal ideation as an element of impoverished consideration sets resulting from a search for solutions under cognitive constraints and mood‐congruent Pavlovian influences, a view supported by mostly indirect evidence. More compelling is the evidence of impaired learning in people with a history of suicidal behavior. We speculate that an inability to simulate alternative futures using one's model of the world may undermine alternative solutions in a suicidal crisis. The hypothesis supported by the strongest evidence is that the selection of suicide over alternatives is facilitated by a choice process undermined by randomness. Case–control studies using gambling tasks, armed bandits, and delay discounting support this claim. Future experimental studies will need to uncover real‐time dynamics of choice processes in suicidal people. In summary, the decision process framework sheds light on neurocognitive mechanisms that facilitate the progression of the suicidal crisis.

This article is categorized under:

Economics > Individual Decision‐Making

Psychology > Emotion and Motivation

Psychology > Learning

Neuroscience > Behavior

Risk factors for suicide attempt in children, adolescents, and young adults hospitalized for mental health disorders

BACKGROUND

Suicide is a leading cause of death among children, adolescents, and young adults (AYA), and mental health disorders are a major contributing factor. Yet, suicidal behaviors among children and AYA with mental health concerns remain understudied and age-specific risk factors are poorly understood. We examined the risk factors for suicide attempt in children and AYA with mental health disorders across three age groups: pre-adolescent children (aged ≤ 12), adolescents (aged 13-17), and young adults (aged 18-25).

METHODS

A cross-sectional study of children and AYA hospitalized for a mental health disorder (n = 18,018) at a private hospital system with 141 facilities across the United States (year 2014).

RESULTS

Suicide attempts six months prior to hospitalization were reported in 12.1% (n = 177) pre-adolescent children, 22% (n = 1476) adolescents, and 17.9% (n = 1766) young adults. Evidence of psychological trauma was present in 55.4% of pre-adolescent children, 51.2% of adolescents, and 44.5% of young adults. Predictors for suicide attempt observed across all three age groups included the following: female sex, depressive disorder, and being a victim of bullying. Risk factors for suicide attempt specific to pre-adolescent children included being uninsured and having an unsafe home or school environment. Among AYA, suicide attempt was associated with non-Hispanic white, family history of suicide, emotional traumas, and other traumatic experiences. Alcohol use disorder was also a significant predictor of suicide attempt in young adults.

CONCLUSIONS

Suicide attempts among children and AYA admitted to a hospital with mental health concerns are highly prevalent. Socioeconomic stressors appeared to be an important contributing factor of suicidal behavior in pre-adolescent children but not in older AYA. Effective suicide prevention strategies targeting children and AYA would need to consider age-specific risk factors.

Adolescent girls' stress responses as prospective predictors of self-injurious thoughts and behaviors: A person-centered, multilevel study

Adolescent risk for self-injurious thoughts and behaviors (STBs) involves disturbance across multiple systems (e.g., affective valence, arousal regulatory, cognitive and social processes). However, research integrating information across these systems is lacking. Utilizing a multiple-levels-of-analysis approach, this person-centered study identified psychobiological stress response profiles and linked them to cognitive processes, interpersonal behaviors, and STBs. At baseline, adolescent girls (N = 241, Mage = 14.68 years, Range = 12-17) at risk for STBs completed the Trier Social Stress Test (TSST), questionnaires, and STB interviews. Positive affect (PA), negative affect (NA), and salivary cortisol (SC) were assessed before and after the TSST. STBs were assessed again during 3, 6, and 9 month follow-up interviews. Multitrajectory modeling of girls' PA, NA, and SC revealed four profiles, which were compared on cognitive and behavioral correlates as well as STB outcomes. Relative to normative, girls in the affective distress, hyperresponsive, and hyporesponsive subgroups were more likely to report negative cognitive style (all three groups) and excessive reassurance seeking (hyporesponsive only) at baseline, as well as nonsuicidal self-injury (all three groups) and suicidal ideation and attempt (hyporesponsive only) at follow-up. Girls' close friendship characteristics moderated several profile-STB links. A synthesis of the findings is presented alongside implications for person-centered tailoring of intervention efforts.

Elucidating the Impact of Childhood, Adulthood, and Cumulative Lifetime Trauma Exposure on Psychiatric Symptoms in Early Schizophrenia Spectrum Disorders

Cumulative lifetime trauma has a profound impact on the development of schizophrenia spectrum disorders. However, few studies have determined participants' most distressing (i.e., "worst") life event in childhood or adulthood or examined whether this event contributes to poorer clinical outcomes. The present study aimed to (a) determine the associations between the worst life event and demographic/clinical variables and (b) examine the associations between the worst life event and psychiatric symptoms (i.e., positive, negative, depressive, and anxiety symptoms). Participants (N = 150) were outpatients newly diagnosed with schizophrenia spectrum disorders who were assessed for lifetime trauma exposure, positive and negative symptoms of schizophrenia, and symptoms of depression and anxiety. Multinomial logistic regression analysis was conducted to examine the associations between demographic and clinical variables and worst life events (none, childhood, or adulthood). Multiple linear regression analyses were performed to examine the associations between worst life events and psychiatric symptoms. More participants reported that their worst life event occurred during adulthood (31.1%) than childhood (21.3%). Adulthood trauma was associated with male gender, older age, non-Chinese ethnicity, and psychiatric comorbidities; childhood trauma was associated with a family history of depression/anxiety. Adulthood trauma was significantly associated with more severe positive psychotic symptoms, f² = 0.19, whereas childhood and adulthood trauma exposure were both significantly associated with more severe depressive and anxiety symptoms, f² s = 0.19 and 0.25, respectively. Our findings underscore the importance of conducting assessments for worst life events and the associated risk factors to develop meaningful formulations and appropriate trauma-focused treatment plans.

Examining the Relationship Between the Use of a Mobile Peer-Support App and Self-Injury Outcomes: Longitudinal Mixed Methods Study

BACKGROUND

Many individuals who self-injure seek support and information through online communities and mobile peer-support apps. Although researchers have identified risks and benefits of participation, empirical work linking participation in these web-based spaces to self-injury behaviors and thoughts is limited.

OBJECTIVE

This study aims to investigate the relationship between behavioral and linguistic traces on a mobile peer support app and self-injury outcomes.

METHODS

Natural use data and web-based surveys (N=697) assessing self-injury outcomes were collected from 268 users (aged 13-38 years; median 19; 149/268, 55.6% female) of a mobile peer-support app for 4 months. Participants were identified as having posted self-injury content using an internal classifier. Natural log data was used to predict self-injury outcomes in a series of multilevel logistic and linear regressions.

RESULTS

Greater engagement on a mobile peer-support app was associated with a decreased likelihood of self-injury thoughts (odds ratio [OR] 0.25, 95% CI 0.09-0.73) and fewer intentions to self-injure (b=-0.37, SE 0.09), whereas posting triggering content was associated with an increased likelihood of engaging in behaviors (OR 5.37, 95% CI 1.25-23.05) and having self-injury thoughts (OR 17.87, 95% CI 1.64-194.15). Moreover, viewing triggering content was related to both a greater ability to resist (b=1.39, SE 0.66) and a greater intention to self-injure (b=1.50, SE 0.06).

CONCLUSIONS

To our knowledge, this is the first study to connect naturally occurring log data to survey data assessing self-injury outcomes over time. This work provides empirical support for the relationship between participation in online forums and self-injury outcomes, and it articulates mechanisms contributing to this relationship.

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.

Maladaptive cognitive emotion regulation strategies and positive symptoms in schizophrenia spectrum disorders: The mediating role of global emotion dysregulation

Previous studies have identified a positive association between maladaptive cognitive emotion regulation strategies and positive symptoms (e.g., hallucinations and delusions) among patients with schizophrenia spectrum disorders. However, translating this finding to clinical practice is challenging. Some patients are reported to experience difficulties in correcting the use of maladaptive cognitive emotion regulation strategies in psychological therapy, which may be due to an underlying effect of global emotion dysregulation. Therefore, the present study aimed to determine the mediating or moderating role of global emotion dysregulation in the relationship between maladaptive cognitive emotion regulation strategies and positive symptoms. A total of 123 newly diagnosed patients with schizophrenia spectrum disorders completed self-report measures of maladaptive cognitive emotion regulation strategies (rumination, catastrophic thinking, self-blame, other-blame) and global emotion dysregulation. The severity of positive symptoms was rated on the Brief Psychiatric Rating Scale-Expanded. Mediation and moderation analyses were performed to test the hypothesized models. Mediation analysis revealed that global emotion dysregulation mediated the relationship between maladaptive cognitive emotion regulation strategies and positive symptoms after controlling for age, gender, ethnicity, duration of untreated psychosis, medication dosage, psychiatric comorbidities, and family history of mental illness (R² = 23.3%, moderate effect size = 0.30). There was no moderating effect of global emotion dysregulation. The present study presents preliminary evidence on the mediating role of global emotion dysregulation in the relationship between maladaptive cognitive emotion regulation strategies and positive symptoms in schizophrenia spectrum disorders. This finding adds to our current understanding on emotion regulation phenomena in schizophrenia spectrum disorders.

Annual Research Review: A meta-analytic review of worldwide suicide rates in adolescents

Suicide is a leading cause of death among youth worldwide. The purpose of the current review was to examine recent cross-national trends in suicide mortality rates among 10- to 19-year-olds. This study extracted suicide mortality data from the World Health Organization's (WHO) Mortality Database for the most recent year (since 2010) from any country with available high-quality data (as defined by the WHO's guidelines). Data on access to lethal means (firearms, railways) and measures of economic quality (World Bank Income Group) and inequality (Gini coefficients) were obtained from publicly available data sources. Cross-national suicide mortality rates in youth were heterogeneous. The pooled estimate across all ages, sexes, and countries was 3.77/100,000 people. The highest suicide rates were found in Estonia, New Zealand, and Uzbekistan. Suicide rates were higher among older compared with younger adolescents and higher among males than females. The most common suicide methods were hanging/suffocation and jumping/lying in front of a moving object or jumping from a height. Firearm and railway access were related to suicide deaths by firearms and jumping/lying, respectively. Economic quality and inequality were not related to overall suicide mortality rates. However, economic inequality was correlated with a higher ratio of male:female suicides. This study provides a recent update of cross-national suicide trends in adolescents. Findings replicate prior patterns related to age, sex, geographic region, and common suicide methods. New to this review are findings relating suicide method accessibility to suicide mortality rates and the significant association between income inequality and the ratio of male:female suicide. Future research directions include expanding the worldwide coverage to more low- and middle-income countries, examining demographic groupings beyond binary sex and to race/ethnicity within countries, and clarifying factors that account for cross-national differences in suicide trends.

Editorial: Identifying Predictors of Treatment Response Trajectories of Suicidal Adolescents

In this issue of the Journal, Abbott et al.¹ present findings from an important secondary analysis of a randomized controlled trial that identifies predictors of treatment response. Previous research has highlighted the importance of varying trajectories of treatment response.^2,3 There is a need to identify factors related to varied treatment outcomes. Determining those who will benefit from treatment compared to those who will not is an important step to personalizing treatments.

Implicit Cognition and Psychopathology: Looking Back and Looking Forward

Implicit cognitive processing is theorized to have a central role in many forms of psychopathology. In the current review, we focus on implicit associations, by which we mean evaluative representations in memory that are difficult to control and do not require conscious reflection to influence affect, cognition, or behavior. We consider definitional and measurement challenges before examining recent empirical evidence for these associations in anxiety, obsessive–compulsive, posttraumatic stress, depressive, and alcohol use disorders. This examination is framed by a brief review of the ways that prominent models of psychopathology represent biased implicit processing of disorder-relevant information. We consider to what extent models reflect more traditional automatic/implicit versus strategic/explicit dual-process perspectives or reflect more recent dynamical systems perspectives in which mental representations are iteratively reprocessed, evolving continuously. Finally, we consider the future research needed to better understand the interactive and temporal dynamics of implicit cognition in psychopathology.