The death-implicit association test and suicide attempts: a systematic review and meta-analysis of discriminative and prospective utility

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

OBJECTIVE

Relevant implicit markers of suicidal thoughts and behaviors (STBs) have only been studied in isolation with mixed evidence. This is the first study that investigated a suicide attentional bias, a death-identity bias and a deficit in behavioral impulsivity in a high-risk sample and healthy controls.

METHOD

We administered the Death Implicit Association Test, the Modified Suicide Stroop Task, and a Go/No-Go Task to inpatient suicide ideators (n = 42), suicide attempters (n = 40), and community controls (n = 61).

RESULTS

Suicide ideators and attempters showed a suicide attentional bias and a death-identity bias compared to healthy controls. Ideators and attempters did not differ in these implicit information-processing biases. Notably, only attempters were more behaviorally impulsive compared to controls; however, ideators and attempters did not significantly differ in behavioral impulsivity. Moreover, implicit scores were positively intercorrelated in the total sample.

CONCLUSION

In line with the Cognitive Model of Suicide, ideators and attempters display suicide-related information processing biases, which can be considered as implicit cognitive markers of suicide vulnerability. Furthermore, attempters have elevated levels of behavioral impulsiveness. These results are highly relevant in the context of crisis intervention strategies and warrant further research.

'Interesting' or 'boring': Modifying the implicit association task to measure implicit fire interest in an adolescent community sample

The efficacy of explicit measures in assessing fire interest is often compromised by social desirability biases, presenting a challenge for early intervention programs aimed at preventing firesetting behaviour. The current study aimed to validate a novel fire interest Implicit Association Task (IAT), as a more reliable measure of implicit fire interest in adolescents. An Australian community adolescent sample of 85 participants, aged 10-17 (M = 13.65, SD = 1.81), completed a series of questionnaires, and the novel fire interest IAT. Based on self-reports, participants were classified as firelighters (n = 52) or non-firelighters (n = 33). IAT outcomes revealed an inclination towards associating "fire" with "interesting." Notably, firelighters, compared to non-firelighters, performed significantly quicker during hypothesis-consistent trials of the IAT where fire-images were paired with interesting-words. Moreover, a weak correlation emerged between the speed of responses in these hypothesis-consistent IAT trials and self-reported fire interest. This investigation is one of the few that examined the efficacy of implicit measures of fire interest and is the first to do so using a modified IAT. With continued refinement, the fire interest IAT could be successfully used to assist with early intervention programs aimed at preventing child firesetting behaviour. PsychINFO Code: 3230.

Prevalence and related factors of first-time suicide attempts in the past 14 days in Chinese adult patients with first-episode drug-naïve major depressive disorder

Background

This study aimed to identify socio-demographic, physiologic, and psychologic related factors of the first-time suicide attempt (FSA) in the past 14 days in Chinese adult patients with first-episode drug-naïve (FEDN) major depressive disorder (MDD).

Methods

A total of 1718 adult patients with FEDN MDD were enrolled in this cross-sectional survey. Depression, anxiety symptoms, and suicide attempts were assessed. Additionally, biological samples were collected and measured, while Logistic regression analysis was employed to explore the risk factors for FSA in the past 14 days among FEDN MDD patients.

Results

Among suicide attempters, 12.11% (208 out of 1718) reported experiencing FSA in the past 14 days. Logistic regression analysis showed that the risk factors for FSA included more severe anxiety symptoms (OR=1.37, 95%CI: 1.28-1.48, p<0.001), higher levels of total cholesterol (TC) (OR=1.42, 95%CI: 1.13-1.77, p=0.003), and elevated thyroid-stimulating hormone (TSH) (OR=1.13, 95%CI: 1.03-1.25, p=0.01). The regression model exhibited good discriminatory power for FSA with an area under the curve (AUC) of 0.82.

Conclusion

FEDN MDD patients with more severe anxiety and higher levels of TSH and TC are more likely to develop FSA in the past 14 days. These factors are risk factors for short-term (in the past 14 days) FSA and may serve as indicators for early intervention.

Multi-method assessment of suicidal thoughts and behaviors among patients in treatment for OCD and related disorders

Obsessive-compulsive and related disorders (OCRDs) are associated with increased risk of suicidal thoughts and behaviors (STBs), yet research characterizing suicidality in OCRDs remains limited. A major challenge in assessing STBs is the reliance on explicit self-report. This study utilized multi-method assessment to examine changes in both implicit and explicit STBs in 31 adults receiving partial/residential treatment for OCRDs. Assessments were administered at admission and weekly during treatment. Approximately three-quarters of participants reported lifetime suicidal thoughts, with 16 % reporting a prior suicide attempt. OCD severity was significantly correlated with lifetime suicidal thoughts, and was significantly higher for those with lifetime suicidal thoughts and prior attempts compared to those without. Implicit biases towards death were not associated with OCD severity, and did not predict explicitly endorsed STBs. This is the first study to measure both explicit and implicit STBs in adults with OCRDs. Limitations included small sample size and lack of racial/ethnic diversity. Given the majority had recent suicidal thoughts and one in six had a prior attempt, we emphasize the importance of STB assessment in OCD treatment settings.

Implicit or explicit self-associations with life and death? Predicting short-term self-injurious thoughts and behaviors among adolescents

Implicit self-association with death, measured by the Death/Suicide-Implicit Association Test (D/S-IAT), predicts short-term Self-Injurious Thoughts and Behaviors (SITBs) among adolescents. However, comparing the predictive utility of the D/S-IAT with explicit (i.e. self-report) self-association with life and death was not examined previously. The current study sought to examine whether the D/S-IAT and explicit self-association with life and death predict current and prospective SITBs, and to examine the association between the two measures. One-hundred and thirty-one Jewish Israeli adolescents with SITBs, aged 10-18 years (74.8% female) were assessed at clinic intake. Participants completed D/S-IAT, depression, attitudes toward life and death and suicide risk assessment at intake and one-month follow-up. Implicit, rather than explicit, attitudes toward life and death predicted SITBs at one-month follow-up, beyond depression and past SITBs. The implicit and explicit measures were not significantly related at intake, indicating that they might capture different aspects of SITBs.

How do explicit, implicit, and sociodemographic measures relate to concurrent suicidal ideation? A comparative machine learning approach

INTRODUCTION

Suicide is a leading cause of death, and decades of research have identified a range of risk factors, including demographics, past self-injury and suicide attempts, and explicit suicide cognitions. More recently, implicit self-harm and suicide cognitions have been proposed as risk factors for the prospective prediction of suicidal behavior. However, most studies have examined these implicit and explicit risk factors in isolation, and little is known about their combined effects and interactions in the prediction of concurrent suicidal ideation.

METHODS

In an online community sample of 6855 participants, we used different machine learning techniques to evaluate the utility of measuring implicit self-harm and suicide cognitions to predict concurrent desire to self-harm or die.

RESULTS

Desire to self-harm was best predicted using gradient boosting, achieving 83% accuracy. However, the most important predictors were mood, explicit associations, and past suicidal thoughts and behaviors; implicit measures provided little to no gain in predictive accuracy.

CONCLUSION

Considering our focus on the concurrent prediction of explicit suicidal ideation, we discuss the need for future studies to assess the utility of implicit suicide cognitions in the prospective prediction of suicidal behavior using machine learning approaches.

Predicting suicidal ideation in psychiatrically hospitalized veterans using the death/suicide Implicit Association Test: A prospective cohort study

INTRODUCTION

We investigated whether the Death/Suicide Implicit Association Test (D/S-IAT) predicted suicidal ideation (SI) in psychiatric inpatients.

METHODS

One hundred eighty veterans admitted for either SI or suicidal behavior (SB) (the primary sample) (N = 90) or alcohol detoxification (N = 90) completed the D/S-IAT and scales measuring SI. Correlation and regression coefficients were measured between the D/S-IAT (as a full-scale or dichotomized score [D > 0]) and self-reported current or imminent SI (over the next 1-3 days).

RESULTS

In the primary sample, the full-scale D/S-IAT was significantly correlated with the intensity of current SI (r = 0.22, p = 0.04) and especially with wishes to be dead (r = 0.35, p < 0.001). The intensity of imminent SI was significantly predicted by the full-scale (p = 0.02) and dichotomized D/S-IAT score (p = 0.05) in a multiple regression model. However, no significant associations were observed when both the D/S-IAT score and current (present/absent) or imminent SI (occurred/did not occur) were dichotomous measures. In participants receiving alcohol detoxification, the D/S-IAT significantly predicted only wishes to be dead (r = 0.33, p < 0.001).

CONCLUSION

The full-scale D/S-IAT score predicted the current intensity of wishes to be dead in both inpatient samples, and current and imminent SI in participants admitted for SI/SB. The dichotomized D/S-IAT score did not predict the simple occurrence of SI.

Implicit Identification with Death, Clinician Evaluation and Suicide Ideation among Adolescent Psychiatric Outpatients-The Mediating Role of Depression

Implicit identification with death (i.e., subconsciously self-associating oneself with death), measured by the Death-Suicide Implicit Association Test (D/S-IAT), is associated with Suicide Ideation (SI). Our understanding of the mechanisms underlying this association is limited. The current study examined (1) the mediating role of depression between D/S-IAT and recent SI and (2) the association between SI, D/S-IAT, and clinician evaluation of SI among a clinical sample of adolescents. 148 adolescents aged 10-18 years (69.4% female) from two outpatient clinics were assessed at intake. Participants completed D/S-IAT and self-report measures for recent SI and depression during intake. Findings indicate that depression is a mediator between D/S-IAT and recent SI, controlling for gender, site differences, and past suicidal thoughts and behaviors. D/S-IAT and clinician evaluation were correlated with recent SI but not beyond depression. Our findings highlight the importance of examining the underlying psychological mechanisms regarding the association between D/S-IAT and suicide.

Implicit cognitions on self-injurious and suicidal behavior in borderline personality disorder

BACKGROUND AND OBJECTIVES

Performance on implicit measures of suicidality has been associated with suicidal and nonsuicidal self-injury. Despite the high prevalence of self-harm in patients with borderline personality disorder (BPD), no previous study has assessed implicit measures in this patient group.

METHODS

Forty patients with BPD and 25 healthy controls completed three implicit association tests (IATs) (Death words - Me/Others words, Self-Harm pictures - Me/Others, and Self-Harm pictures - Good/Bad words) and a subliminal priming task (effect of the primes "dying"/"growing" on the categorization speed of positive/negative adjectives) as well as measures of psychopathology (suicidal ideation, previous nonsuicidal self-injury, borderline symptomatology, depression, and hopelessness).

RESULTS

Patients with BPD had higher scores on all three IATs than healthy controls. The subliminal priming procedure did not reveal group differences. Correlations between implicit measures and psychopathology among patients with BPD were mostly weak and nonsignificant with a few exceptions: Positive correlations were observed between IAT Self-Harm - Good/Bad and lifetime frequency of nonsuicidal self-injury, between IAT Self-Harm - Me/Others and depression, and between IAT Death - Me/Others and depression. Correlations between implicit measures were weak to moderate.

LIMITATIONS

The study was cross-sectional only, and the study had reduced power as the sample size was limited.

CONCLUSIONS

As expected, patients with BPD had higher scores than healthy controls on the IATs, which indicates higher implicit self-identification with self-harm and death as well as stronger implicit positive attitudes towards self-harm. The mostly weak correlations between implicit and explicit measures speak against the discriminative value of IATs in patients with BPD.

Suicidality and mood: the impact of trends, seasons, day of the week, and time of day on explicit and implicit cognitions among an online community sample

Decades of research have established seasonality effects on completed and attempted suicides, with rates increasing in spring. Little advancements have been made to explain this phenomenon, with most studies focusing almost exclusively on the number of suicide attempts and deaths. Using more than six years of data collected among a US, UK, and Canadian online community sample (N > 10,000), we used newly developed Prophet forecasting and autoregressive-integrated moving average time-series models to examine the temporal dynamics of explicit and implicit self-harm cognitions. We created three groups (past suicide attempters; suicide ideation and/or non-suicidal self-injury; no previous self-harm, suicidal thoughts, or behaviors). We found a general increase of negative self-harm cognitions across the six years and seasonality effects for mood and desire to die, particularly among those who previously made a suicide attempt. Negative explicit self-harm cognitions peaked in winter (December), with implicit self-harm showing a lagged peak of two months (February). Moreover, daily negative self-harm cognitions consistently peaked around 4-5 am, with implicit cognitions again showing a lagged effect (1-hour). Limitations include the volunteer sample not being representative and the cross-sectional nature of the data being unable to separate between-subject and within-subject structural trends in the time series. Our findings show that negative explicit and implicit cognitions precede the rise in suicidal behaviors in spring. We proposed a conceptual model of seasonal suicide risk that may offer fertile ground for theoretical advancements, including implications for clinical risk assessment and public policies regarding the availability of health services.

Implementing Evidence-Based Suicide Prevention Strategies for Greatest Impact

Suicide remains a leading cause of death in the United States and globally. In this review, epidemiological trends in mortality and suicide risk are presented, with consideration given to the impact of the COVID-19 pandemic. A public health model of suicide prevention with a community and clinical framework, along with advances in scientific discovery, offer new solutions that await widespread implementation. Actionable interventions with evidence for reducing risk for suicidal behavior are presented, including universal and targeted strategies at community, public policy, and clinical levels. Clinical interventions include screening and risk assessment; brief interventions (e.g., safety planning, education, and lethal means counseling) that can be done in primary care, emergency, and behavioral health settings; psychotherapies (cognitive-behavioral, dialectical behavior, mentalization therapy); pharmacotherapy; and systemwide procedures for health care organizations (training, policies, workflow, surveillance of suicide indicators, use of health records for screening, care steps). Suicide prevention strategies must be prioritized and implemented at scale for greatest impact.

Implicit identification with death detects and predicts short-term suicide risk among adolescents discharged from the emergency room

BACKGROUND

Implicit identification with death, measured by the Death-Suicide-Implicit Association Test (D/S-IAT), has been found to predict long-term suicide risk among adolescents. However, previous studies did not examine the predictive utility of D/S-IAT on short-term suicide risk trajectories among adolescents, especially during the critical period following discharge from the emergency room (ER) due to suicide behaviors.

OBJECTIVE

This study examined the ability of the D/S-IAT to discriminate and predict suicide risk trajectories during the month following initial suicide risk assessment, among adolescents recently discharged from the ER.

METHODS

One hundred and fifteen adolescents aged 9-18 years (77.4% female) were assessed at clinic intake. All participants completed D/S-IAT and self-report measures for suicide risk, depression, and anxiety during intake and 1-month follow-up.

RESULTS

The D/S-IAT distinguished and predicted participants with continued heightened suicide risk at follow-up, above and beyond depression, anxiety, and suicide risk level at intake.

CONCLUSIONS

Along with conventional measures, D/S-IAT may be utilized to predict short-term suicide risk during post-ER discharge.

Using Behavioral Measures to Assess Suicide Risk in the Psychiatric Emergency Department for Youth

Suicide screening is critical in pediatric emergency departments (EDs). Behavioral measures of suicide risk may complement self-report measures. The current study examines suicide-specific behavioral measures and tests their potential short-term within-person effects among respondents, ability to discriminate future suicide attempt from suicidal ideation, and translation into interpretable categorical composite scores. The sample included 167 youth (10-17 years), presenting for suicide-related reasons to a pediatric psychiatric ED. During their ED visit, participants completed the Death/Life Implicit Association Test (IAT) and the Suicide Stroop Task. Recurrent suicidal thoughts and attempts were assessed within 6 months of the ED visit via medical records and email surveys. Youth displayed a decrease in the levels of distress and self-injurious desires (negative mood, desire to hurt themselves, and desire to die) after completing the behavioral tasks. The Death/Life IAT prospectively differentiated with 68% accuracy between youth who attempted suicide after their ED visit and those who had suicidal ideation but no attempt, p = 0.04, OR = 5.65, although this effect became marginally significant after controlling for self-report and demographic covariates. Neither the Suicide Stroop Task, nor the categorical composite scores predicted suicide attempts, ps = 0.08-0.87, ORs = 0.96-3.95. Behavioral measures of suicide risk administered in the ED do not appear to increase distress or self-injurious desires. They may be able to distinguish those who go on to attempt suicide (vs. consider suicide) within six months after discharge.

Testing the practical utility of implicit measures of beliefs for predicting drunk driving

Despite the potential benefits of implicit measures over self-report measures, they are rarely used in real-world contexts to predict behavior. Two potential reasons are that (a) traditional implicit measures typically show low predictive validity and (b) the practical utility of implicit measures has hardly been investigated. The current studies test the practical utility of a new generation of implicit measures for predicting drunk driving. Study 1 (N = 290) examined whether an implicit measure of beliefs about past drunk driving (i.e., the Past Driving Under the Influence Implicit Association Test; P-DUI-IAT) retrospectively predicts drunk driving in driving school students, a population for which this measure could have applied value. Study 1 also explored whether P-DUI-IAT scores prospectively predicted drunk driving over six months. Due to the low number of offenders, however, Study 1 had low statistical power to test this latter question. In Study 2 (N = 228), we therefore examined the utility of the P-DUI-IAT and a new variant of this test (i.e., the Acceptability of Driving Under the Influence Implicit Association Test; A-DUI-IAT) to prospectively predict drunk driving in an online sample with a high number of offenders. Results from Study 1 show that the P-DUI-IAT predicts self-rated past drunk driving behavior in driving school students (ORs = 3.11–6.12, ps < .043, 95% CIs = [1.11, 37.69]). Results from Study 1 do not show evidence for utility of the P-DUI-IAT to prospectively predict self-rated drunk driving. Results from Study 2, on the other hand, show strong evidence for the utility of both implicit measures to prospectively predict self-rated drunk driving (ORs = 3.80–5.82, ps < .002, 95% CIs = [1.72, 14.47]). Although further applied research is necessary, the current results could provide a first step towards the application of implicit measures in real-world contexts.

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.

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

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