The cost of social punishment and high-lethality suicide attempts in the second half of life

Social decision-making in major depressive disorder: A three-level meta-analysis

Major Depressive Disorder (MDD) is frequently associated with social dysfunction and impaired decision-making, but its impact on social decisions remains unclear. Thus, we conducted a series of meta-analyses to examine the effects of MDD on key social decision phenomena, including trust, altruistic punishment, and cooperation. We searched Web of Science, PubMed, PsycINFO, and Embase up to December 2023, using Hedges' g to compare social decision-making between MDD patients and healthy controls (HCs). Meta-analytic results showed that MDD patients exhibited a significant reduction in trust (Hedges' g = -0.347, p < 0.001), no significant difference in altruistic punishment (Hedges' g = 0.232, p = 0.149), and an increase in cooperative behaviors (Hedges' g = 0.361, p = 0.002) compared to HCs. The moderation analysis revealed that age (p = 0.039) and region (p = 0.007) significantly moderated altruistic punishment, with older MDD patients and those from Asian and European regions having larger MDD-HC contrast than others. Regarding cooperation, moderation analysis indicated that age (p = 0.028), years of education (p = 0.054), and treatment coverage (p = 0.042) were significant moderators, indicating larger MDD-HC contrast in older, less-educated and better-treated people. These findings suggest MDD has different impacts on different social decisions, highlighting the need for fine-tuned therapeutic interventions that address these differences. The data also underscores the importance of considering demographic and treatment-related variables in managing MDD, which could inform personalized treatment strategies and improve social functionality and patient outcomes.

Improving social reward responsivity and social connectedness in psychotherapies for late-life depression: Engage & Connect as an example

Psychotherapies are effective in reducing late-life depression. Yet, about half of patients remain depressed at treatment end. Advances in neuroscience can inform simplified interventions that target key brain networks impacted by depression. Behavioral activation therapies that increase social connectedness may improve social reward responsivity and alter abnormalities of the Positive Valence System (PVS). Engage & Connect is an example for a scalable and simple neuroscience-informed psychotherapy, aimed to improve PVS functions and social reward responsivity by increasing engagement in rewarding social activities. Interventions that improve social reward responsivity can be promising first-line treatments for late-life depression in the community.

Neural responses to social decision-making in suicide attempters with mental disorders

BACKGROUND

Decision-making deficits have been reported in suicide attempters and may be a neuropsychological trait of vulnerability to suicidal behavior. However, little is known about how neural activity is altered in decision-making. This study aimed to investigate the neural responses in suicide attempters with mental disorders during social decision-making. Electroencephalography (EEG) were recorded from 52 patients with mental disorders with past suicide attempts (SAs = 26) and without past suicide attempts (NSAs = 26), as well as from 22 age- and sex- matched healthy controls (HCs) during the Ultimatum Game (UG), which is a typical paradigm to investigate the responses to fair and unfair decision-making.

METHODS

MINI 5.0 interview and self report questionnaire were used to make mental diagnosis and suicide behavior assessment for individuals. Event-related potential (ERP) and phase-amplitude coupling (PAC) were extracted to quantify the neural activity. Furthermore, Spearman correlation and logistic regression analyses were conducted to identify the risk factors of suicidal behavior.

RESULTS

ERP analysis demonstrated that SA patients had decreased P2 amplitude and prolonged P2 latency when receiving unfair offers. Moreover, SA patients exhibited greater negative-going feedback-related negativity (FRN) to unfair offers compared to fair ones, whereas such a phenomenon was absent in NSA and HC groups. These results revealed that SA patients had a stronger fairness principle and a disregard toward the cost of punishment in social decision-making. Furthermore, theta-gamma and beta-gamma PAC were involved in decision-making, with compromised neural coordination in the frontal, central, and temporal regions in SA patients, suggesting cognitive dysfunction during social interaction. Statistically significant variables were used in logistic regression analysis. The area under receiver operating characteristic curve in the logistic regression model was 0.91 for SA/HC and 0.84 for SA/NSA.

CONCLUSIONS

Our findings emphasize that suicide attempts in patients with mental disorders are associated with abnormal decision-making. P2, theta-gamma PAC, and beta-gamma PAC may be neuro-electrophysiological biomarkers associated with decision-making. These results provide neurophysiological signatures of suicidal behavior.

What distinguishes high and low-lethality suicide attempts in older adults? A systematic review and meta-analysis

Those making suicide attempts with highly lethal medical consequences are arguably the best proxy for those who die by suicide and represent a qualitatively different population from those making lower lethality attempts. Different factors influence the likelihood of a suicide attempt occurring and the lethality of that attempt. Both are important dimensions of risk. Older adults represent a distinct group in suicide research with unique risk factors that influence the lethality of their suicide attempts. This systematic review and meta-analysis summarises factors distinguishing those making high and low-lethality suicide attempts in older adulthood. Databases PsycINFO, PubMed (MEDLINE), Embase and CINAHL were systematically searched with seven of 1182 unique records included. Random effects meta-analyses were conducted on 18 variables in addition to a narrative synthesis regarding executive function. Only increased suicidal intent and planning meaningfully distinguished high from low-lethality attempters in meta-analyses. A large effect size was additionally observed for white ethnicity. Diminished alcohol use disorder prevalence and depression severity, and greater cognitive impairment, may be associated with high lethality attempters but further research is needed. Age and gender were not associated with lethality, contrary to adult populations. A narrative synthesis of studies exploring differences in executive functioning suggested high-lethality attempters were less likely to impulsively act on suicidal urges, allowing them to better plan suicide attempts that are more lethal, and are less likely to alter suicidal plans. Key limitations were that meta-analyses were underpowered to detect small effect sizes, and samples were largely white and limited to the USA.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Computational Model of Hopelessness and Active-Escape Bias in Suicidality

Currently, psychiatric practice lacks reliable predictive tools and a sufficiently detailed mechanistic understanding of suicidal thoughts and behaviors (STB) to provide timely and personalized interventions. Developing computational models of STB that integrate across behavioral, cognitive and neural levels of analysis could help better understand STB vulnerabilities and guide personalized interventions. To that end, we present a computational model based on the active inference framework. With this model, we show that several STB risk markers - hopelessness, Pavlovian bias and active-escape bias - are interrelated via the drive to maximize one's model evidence. We propose four ways in which these effects can arise: (1) increased learning from aversive outcomes, (2) reduced belief decay in response to unexpected outcomes, (3) increased stress sensitivity and (4) reduced sense of stressor controllability. These proposals stem from considering the neurocircuits implicated in STB: how the locus coeruleus - norepinephrine (LC-NE) system together with the amygdala (Amy), the dorsal prefrontal cortex (dPFC) and the anterior cingulate cortex (ACC) mediate learning in response to acute stress and volatility as well as how the dorsal raphe nucleus - serotonin (DRN-5-HT) system together with the ventromedial prefrontal cortex (vmPFC) mediate stress reactivity based on perceived stressor controllability. We validate the model by simulating performance in an Avoid/Escape Go/No-Go task replicating recent behavioral findings. This serves as a proof of concept and provides a computational hypothesis space that can be tested empirically and be used to distinguish planful versus impulsive STB subtypes. We discuss the relevance of the proposed model for treatment response prediction, including pharmacotherapy and psychotherapy, as well as sex differences as it relates to stress reactivity and suicide risk.

Low MoCA performances correlate with suicidal ideation in late-life depression

Late-life depression remains an underdiagnosed clinical entity, mainly because the presence of cognitive impairment in the elderly leads clinicians to suspect dementia rather than depression. Our objective was to analyze the cognitive abilities of elderly depressed patients using the Montreal Cognitive Assessment (MoCA) in relation to the presence or absence of suicidal ideation. The MoCA, Beck Scale of Suicidal Ideation, Hamilton Anxiety Scale, and Hamilton Depression Scale were administered to 72 patients with a recent history of late life depression: 43 with suicidal ideation and 29 non-suicidal controls. The results show that suicidal patients demonstrated significantly worse performance on the MoCA total score and the delayed recall subtest in comparison to non-suicidal controls. In addition, after adjusting for age and depression, poorer performance on the MoCA total score correlated to the presence of suicidal ideation. We found that the MoCA total score is able to predict the presence of suicidal ideation in depressed elderly patients in a fair-to-good manner. As late-life depression is already established as a potential prodrome of dementia, longitudinal follow-up may determine whether depressed individuals with suicidal ideation are at higher risk of converting to dementia.

The Serious Suicide Attempts Approach for Understanding Suicide: Review of the Psychological Evidence

The study of survivors of a serious suicide attempt (SSA)--an attempt that would have been fatal had it not been for the provision of rapid and effective emergency treatment--can help researchers understand the suicidal mind. Serious suicide attempters are epidemiologically very similar to those who died by suicide, and thus can serve as valid proxies for studying suicides. In this paper, our objective was to briefly review the main risk factors that may facilitate more dangerous suicide behavior with high levels of intent. Our review highlights several dimensions of risk factors for SSAs, including psychopathology, mental pain, communication difficulties, decision-making impulsivity, and aggression. Several studies have indicated that the interaction between some of these dimensions, especially between mental pain and interpersonal difficulties, may serve as major catalysts for SSAs. Suicidal risk assessment should incorporate a designated evaluation of these risk factors as part of suicide prevention models.

Predictors of serious suicidal behavior in late-life depression

The present study aimed to identify pathways to suicidal behavior in late life that can guide identification of those most at risk and improve treatment. In a longitudinal study of late-life depression, we prospectively assessed risk factors specifically associated with fatal and near-fatal as compared to less lethal suicidal behavior. We enrolled 401 participants (age 66+9.9): 311 with unipolar non-psychotic depression and 90 non-psychiatric controls. The median follow-up was 5.4 years. Results indicated that history of suicide attempt predicted a two-fold increase in the risk of dying from natural causes. In univariate models, male gender, higher income, current depression and current and worst lifetime suicidal ideation severity, cognitive control deficits, and low levels of non-planning impulsivity predicted fatal and near-fatal suicidal behavior. In contrast, incident less lethal suicidal behavior was mostly associated with maladaptive personality traits, impulsivity, and severity of psychiatric illness in univariate models. In multipredictor models, male gender, worst lifetime suicidal ideation, and deficits in cognitive control independently predicted fatal/near-fatal suicidal behavior, while introversion, history of suicide attempt, and earlier age of onset of depression predicted less lethal suicidal behavior. While clinicians may be familiar with suicide risk factors identified in younger samples such as dysfunctional personality, impulsivity, and co-morbid substance use, in late life these characteristics only pertain to lower-lethality suicidal behavior. Cognitive control deficits, which likely play a greater role in old age, predict serious suicidal behavior.

Neurological Changes and Depression: 2020 Update

This article covers current research on the relationship between depression and cognitive impairment in older adults. First, it approaches the clinical assessment of late-life depression and comorbid cognitive impairment. Cognitive risk factors for suicide are discussed. Research is then provided on neuropsychological changes associated with depression, discussing subjective cognitive impairment, mild cognitive impairment, and dementia profiles. In addition, literature regarding neuroimaging and biomarker findings in depressed older adults is presented. Finally, therapeutic models for treatment of late-life depression are discussed, including psychotherapy models, holistic treatments, pharmacologic approaches, and brain stimulation therapies.

Behavioral empathy failures and suicidal behavior

Impaired decision-making has recently gained recognition as a component of the suicidal diathesis. Yet, although precipitants and particularly deterrents to suicidal behavior are often interpersonal, little is known about social decision-making in suicidal individuals. This study employed a novel version of the Ultimatum Game to investigate how empathy moderates responses to social conflict in 149 older adults, comprising groups of suicide attempters (n = 49), suicide ideators (n = 32), non-suicidal depressed controls (n = 33), and a non-psychiatric control group (n = 35). Participants acted as responder to a series of single-shot financial offers that varied in fairness. Some offers were paired with social context information on the proposer, designed to evoke either empathy or punishment. Offer acceptance was sensitive to Fairness and Social Context, such that participants accepted more offers in the empathy condition and fewer offers in the punishment condition. A Group * Context interaction was observed, wherein the suicide attempters adjusted their acceptance rates less in the empathy condition than the non-psychiatric controls. Thus, older adults with a history of suicide attempt were less influenced by empathy scenarios, indicating that a failure to integrate others' emotions into decisions may undermine social deterrents to suicide.

Value-Based Choice, Contingency Learning, and Suicidal Behavior in Mid- and Late-Life Depression

BACKGROUND

Suicidal behavior is associated with impaired decision making in contexts of uncertainty. Existing studies, however, do not definitively address whether suidice attempers have 1) impairment in learning from experience or 2) impairment in choice based on comparison of estimated option values. Our reinforcement learning model-based behavioral study tested these hypotheses directly in middle-aged and older suicide attempters representative of those who die by suicide.

METHODS

Two samples (sample 1, n = 135; sample 2, n = 125) of suicide attempters with depression (n_attempters = 54 and 39, respectively), suicide ideators, nonsuicidal patients with depression, and healthy control participants completed a probabilistic three-choice decision-making task. A second experiment in sample 2 experimentally dissociated long-term learned value from reward magnitude. Analyses combined computational reinforcement learning and mixed-effects models of decision times and choices.

RESULTS

With regard to learning, suicide attempters (vs. all comparison groups) were less sensitive to one-back reinforcement, as indicated by a reduced effect on both choices and decision times. Learning deficits scaled with attempt lethality and were partially explained by poor cognitive control. With regard to value-based choice, suicide attempters (vs. all comparison groups) displayed abnormally long decision times when choosing between similarly valued options and were less able to distinguish between the best and second-best options. Group differences in value-based choice were robust to controlling for cognitive performance, comorbidities, impulsivity, psychotropic exposure, and possible brain damage from attempts.

CONCLUSIONS

Serious suicidal behavior is associated with impaired reward learning, likely undermining the search for alternative solutions. Attempted suicide is associated with impaired value comparison during the choice process, potentially interfering with the consideration of deterrents and alternatives in a crisis.

Reward systems and cognitions in Major Depressive Disorder

A lack of motivation and anhedonia represent frequent and pervasive symptoms in depression, although with poor specificity. Historically described as a response bias, reward-related impairments in depression may account for the important aspects of the cognitive impairments associated with diagnosis of major depressive disorder. Reward processing is a broad psychological construct that can be parsed into 3 distinct components known as "reinforcement learning" (learning), "reward responsiveness" (liking), and "motivation to obtain a reward" (wanting). Depressed patients respond hyposensitively to reward and maladaptively to punishment: this pattern is related to a dysfunction in the frontostriatal systems modulated by the monoamine systems; seems to be observed in medicated and unmedicated patients with depression and in healthy individuals with high levels of anhedonia; and could be observed in patients with a history of depression, even when in full remission. Considered to be cognitive impairments, reward-related-impairments may also constitute part of an underlying neurobiological vulnerability to major depressive disorder (MDD). For example, the reward-related impairment is state dependent and, more or less, correlated with symptom severity in some studies but has also been proposed as being trait like, with endophenotype characteristics, possibly contributing to the persistence of the disease or treatment resistance. The 3 core aspects of reward processing have specific neurobiological correlates that involve the ventral and dorsal striatum, lateral habenula, ventral tegmental area, orbitofrontal cortex, anterior cingulate cortex, and ventromedial and dorsolateral prefrontal cortex. These structures underline the important role of the dopaminergic mesolimbic pathway, but glutamate and serotonin could also have an important role, at least in some aspects of reward-related impairments.

Social cognition and short-term prediction of suicidal ideation in schizophrenia

Despite recent research acknowledging social cognition as an important feature of interpersonal functioning in schizophrenia, little work has evaluated the role of social cognition in suicidal ideation and behavior in psychosis. In a short-term longitudinal study, we evaluated the association between concurrent and near term suicidal ideation with social cognition, including emotion recognition and related biases (ER-40; BLERT), attribution biases (AIHQ), and evaluations of trustworthiness (trustworthiness task) in a sample of 179 outpatients with schizophrenia or schizoaffective disorder. Adjusting for severity of positive and general mental health symptoms, greater reactivity to extreme stimuli (trustworthiness measure), BLERT negative affect accuracy, and AIHQ Blame Scores were associated with suicidal ideation at baseline. AIHQ Blame Scores also longitudinally predicted the presence of ideation 2 weeks later and were highest among participants with ideation across the two time points. The present findings provide support that biased interpretations, and, concurrently with ideation, reactivity and selective accuracy to negative stimuli, are associated with suicidal ideation in schizophrenia. Further understanding the role of social cognitive ability and biases on suicidal ideation could contribute to the understanding of social cognition as a treatment target in prevention of suicidal behavior in schizophrenia.

Neuroimaging-informed phenotypes of suicidal behavior: a family history of suicide and the use of a violent suicidal means

The identification of brain markers of suicidal risk is highly expected. However, neuroimaging studies have yielded mixed results, possibly due to phenotypic heterogeneity. In the present study, we addressed this issue using structural brain imaging. First, two independent samples of suicide attempters (n = 17 in Montreal, 32 in Jena), patient controls (n = 26/34), and healthy controls (n = 66/34) were scanned with magnetic resonance imaging. Groups were compared with FSL. We then reviewed the literature and run a GingerALE meta-analysis of 12 structural imaging studies comparing suicide attempters and patient controls with whole-brain analyses (n = 693). Finally, we explored the potential contribution of two variables previously associated with biological/cognitive deficits: a family history of suicide (FHoS), and the use of a violent suicidal means (VSM). Here, we added two groups of healthy first-degree biological relatives of suicide victims and depressed patients (n = 32). When comparing all suicide attempters and controls, very limited between-group differences were found in the two samples, and none in the meta-analysis. In contrast, a FHoS was associated with reduced volumes in bilateral temporal regions, right dorsolateral prefrontal cortex, and left putamen, several of these differences being observed across groups. VSM was associated with increased bilateral caudate (and left putamen) volumes. Some morphometric variations in cortico-subcortical networks may therefore be endophenotypes increasing the suicidal vulnerability, while others (notably in striatum) may modulate action selection. These results therefore confirm at the neural level two phenotypes at high lethal risk with a strong biological background, and uncover motives of heterogeneous findings in neuroimaging studies of suicidal behavior.

Do patients with different psychiatric disorders show altered social decision-making? A systematic review of ultimatum game experiments in clinical populations

BACKGROUND

Impairments in social functioning are a common feature of psychiatric disorders. Game paradigms pose a unique way for studying how people make decisions in interpersonal contexts. In the last decade, researchers have started to use these paradigms to study social decision-making in patients with psychiatric disorders.

PURPOSE

The aim of this systematic literature review is to summarise the currently available evidence on the behaviour of patients with psychiatric disorders in the commonly used Ultimatum Game (UG).

METHOD

A systematic literature search including MEDLINE, PsycINFO, PSYNDEXplus Tests, PSYNDEXPLUS Literature, EBM Reviews-Cochrane Central Register of Controlled Trials, Embase and PASCAL was performed via the Ovid interface.

RESULTS

We found evidence for alterations in UG behaviour for patients with frontotemporal dementia, schizophrenia, affective disorders, alcohol, cocaine, heroin and 3,4-methylenedioxymethamphetamine consumption, alcohol dependence, anxiety disorders, borderline personality disorder, autism, Tourette syndrome and oppositional defiant disorder.

CONCLUSION

There is some evidence that different psychiatric disorders might go along with alterations in social decision-making. However, in general, data are currently limited and studies are hard to compare due to differences in methodologies.

Serious Suicide Attempts: Systematic Review of Psychological Risk Factors

BACKGROUND

One of the main obstacles in studying suicide risk factors is the difference between cases in which the individual died by suicide and those in which the individual engaged in suicidal behavior. A promising strategy that overcomes this obstacle is the study of survivors of serious suicide attempt (SSA), i.e., an attempt that would have been lethal had it not been for the provision of rapid and effective emergency treatment. Serious suicide attempters are epidemiologically very much like those who died by suicide, and thus may serve as valid proxies for studying suicides. This paper aims to define the specific risk factors for SSAs by conducting a qualitative data synthesis of existing studies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search of the literature in PubMed, ProQuest, and Psychlit electronic research-literature databases. Search terms were "serious" "OR" "near lethal," combined with the Boolean "AND" operator with "suicide*." In addition, we performed a manual search on Google Scholar for further studies not yet identified.

RESULTS

The preliminary search identified 683 citations. A total of 39 research reports that met the predefined criteria were analyzed. Mental pain, communication difficulties, decision-making impulsivity, and aggression, as well as several demographic variables, were found to be major risk factors for SSAs.

LIMITATIONS

We found a variability of definitions for SSA that hamper the ability to draw a model for the risk factors and processes that facilitate it. Moreover, the role of suicide intent and planning in SSA is still unclear. Further studies should aim to clarify and refine the concepts and measures of SSA, thereby enabling more specific and concrete modeling of the psychological element in its formation.

CONCLUSION

SSA is a distinguishable phenomenon that needs to be addressed specifically within the scope of suicidal behavior. Interpersonal problems, as well as impulsivity and aggression, seem to facilitate SSA when mental pain serves as a secondary factor. Healthcare professionals should be aware of SSA, and familiar with its specific risk factors. Moreover, psychological and suicidal risk assessment should include a designated evaluation of these risk factors as part of intervention and prevention models for SSA.

Neurologic Changes and Depression

This article covers current research on the relationship between depression and cognitive impairment in older adults. First, it approaches the clinical assessment of late-life depression and comorbid cognitive impairment. Cognitive risk factors for suicide are discussed. Research is then provided on neuropsychological changes associated with depression, discussing subjective cognitive impairment, mild cognitive impairment, and dementia profiles. Additionally, literature regarding neuroimaging and biomarker findings in depressed older adults is presented. Finally, therapeutic models for treatment of late-life depression are also discussed, including psychotherapy models, holistic treatments, pharmacologic approaches, and brain-stimulation therapies.

Response to unfairness across the suicide risk spectrum

Suicidal behavior is frequently triggered by social crises, such as familial, romantic, social or work-related conflict. A variety of cognitive and social functioning impairments has been associated with suicidal thoughts and acts. One of the precipitating and perpetuating factors of social conflict is the desire for retribution after a perceived offense, even at one's own detriment. We utilized the Ultimatum Game-a behavioral economic task which examines the behavioral response to perceived unfairness-in order to characterize the response to unfairness across the acute suicide risk spectrum. We examined five groups of adult individuals of both genders (n = 204): High- and Low-Lethality recent Suicide Attempters, Suicidal Ideators, Non-Suicidal Depressed Patients; and Healthy Controls. We also measured demographic and clinical variables. Even though all depressed groups showed similar rejection rates in the Ultimatum Game, there was a higher likelihood of rejecting offers in the low stakes condition in all acutely suicidal groups compared with healthy controls. Stake size, offer, education, and gender of the proposer were significantly associated with rejection rates. Acutely suicidal patients may be more vulnerable to adverse interpersonal interactions. Further characterization of social behavior may provide targets for secondary and tertiary prevention for high-risk individuals.

The decision neuroscience perspective on suicidal behavior: evidence and hypotheses

PURPOSE OF REVIEW

Suicide attempts are usually regretted by people who survive them. Furthermore, addiction and gambling are over-represented among people who attempt or die by suicide, raising the question whether their decision-making is impaired. Advances in decision neuroscience have enabled us to investigate decision processes in suicidal people and to elucidate putative neural substrates of disadvantageous decision-making.

RECENT FINDINGS

Early studies have linked attempted suicide to poor performance on gambling tasks. More recently, functional MRI augmented with a reinforcement learning computational model revealed that impaired decision-making in suicide attempters is paralleled by disrupted expected value (expected reward) signals in the ventromedial prefrontal cortex. Behavioral studies have linked increased delay discounting to low-lethality/poorly planned attempts, multiple attempts, and the co-occurrence of attempted suicide and addiction. This behavioral tendency may be related to altered integrity of the basal ganglia. By contrast, well-planned, serious suicide attempts were associated with intact/diminished delay discounting. One study has linked high-lethality suicide attempts and impaired social decision-making.

SUMMARY

This emerging literature supports the notion that various impairments in decision-making - often broadly related to impulsivity - may mark different pathways to suicide. We propose that aggressive and self-destructive responses to social stressors in people prone to suicide result from a predominance of automatic, Pavlovian processes over goal-directed computations.

Decision Making in Social Context in Patients with Suicide Attempt History

Decision making has been found to be altered in suicide attempters, but little is known of their performance in social contexts. Twenty-seven depressed suicide attempters (DSA), 25 nonsuicidal depressed patients (DP), and 60 healthy participants (HC) were evaluated by a decision-making task in social context. Results indicated DSA and DP obtained lower gains and invested more money with angry partners. DSA were found to invest less money than DP and HC with happy partners. DSA showed insensitivity toward rewards/punishment contingency, and they did not use the socioemotional stimuli to guide their decisions.

Insomnia is associated with suicide attempt in middle-aged and older adults with depression

BACKGROUND

Insomnia increases in prevalence with age, is strongly associated with depression, and has been identified as a risk factor for suicide in several studies. The aim of this study was to determine whether insomnia severity varies between those who have attempted suicide (n = 72), those who only contemplate suicide (n = 28), and those who are depressed but have no suicidal ideation or attempt history (n = 35).

METHODS

Participants were middle-aged and older adults (age 44-87, M = 66 years) with depression. Insomnia severity was measured as the sum of the early, middle, and late insomnia items from the Hamilton Rating Scale for Depression. General linear models examined relations between group status as the independent variable and insomnia severity as the dependent variable.

RESULTS

The suicide attempt group suffered from more severe insomnia than the suicidal ideation and non-suicidal depressed groups (p < 0.05). Differences remained after adjusting for potential confounders including demographics, cognitive ability, alcohol dependence in the past month, severity of depressed mood, anxiety, and physical health burden. Moreover, greater insomnia severity in the suicide attempt group could not be explained by interpersonal difficulties, executive functioning, benzodiazepine use, or by the presence of post-traumatic stress disorder.

CONCLUSIONS

Our results suggest that insomnia may be more strongly associated with suicidal behavior than with the presence of suicidal thoughts alone. Accordingly, insomnia is a potential treatment target for reducing suicide risk in middle-aged and older adults.

Processing of decision-making and social threat in patients with history of suicidal attempt: A neuroimaging replication study

Suicidal vulnerability has been related to impaired value-based decision-making and increased sensitivity to social threat, mediated by the prefrontal cortex. Using functional magnetic resonance imaging, we aimed at replicating these previous findings by measuring brain activation during the Iowa Gambling Task and an emotional faces viewing task. Participants comprised 15 euthymic suicide attempters (history of depression and suicidal behavior) who were compared with 23 euthymic patient controls (history of depression without suicidal history) and 35 healthy controls. The following five model-based regions of interest were investigated: the orbitofrontal cortex (OFC), ventrolateral prefrontal cortex (VLPFC), anterior cingulate cortex (ACC), medial (MPFC) and dorsal prefrontal cortex (DPFC). Suicide attempters relative to patient controls showed (1) increased response to angry vs. neutral faces in the left OFC and the VLPFC, as previously reported; (2) increased response to wins vs. losses in the right OFC, DPFC and ACC; (3) decreased response to risky vs. safe choices in the left DPFC; and (4) decreased response to sad vs. neutral faces in the right ACC. This study links impaired valuation processing (here for signals of social threat, sadness and reward) to prefrontal cortex dysfunction in suicide attempters. These long-term deficits may underlie the impaired decision-making and social difficulties found in suicide attempters.

Decision-making competence and attempted suicide

OBJECTIVE

The propensity of people vulnerable to suicide to make poor life decisions is increasingly well documented. Do they display an extreme degree of decision biases? The present study used a behavioral-decision approach to examine the susceptibility of low-lethality and high-lethality suicide attempters to common decision biases that may ultimately obscure alternative solutions and deterrents to suicide in a crisis.

METHOD

We assessed older and middle-aged (42-97 years) individuals who made high-lethality (medically serious) (n = 31) and low-lethality suicide attempts (n = 29). Comparison groups included suicide ideators (n = 30), nonsuicidal depressed participants (n = 53), and psychiatrically healthy participants (n = 28). Attempters, ideators, and nonsuicidal depressed participants had nonpsychotic major depression (DSM-IV criteria). Decision biases included sunk cost (inability to abort an action for which costs are irrecoverable), framing (responding to superficial features of how a problem is presented), underconfidence/overconfidence (appropriateness of confidence in knowledge), and inconsistent risk perception. Data were collected between June 2010 and February 2014.

RESULTS

Both high- and low-lethality attempters were more susceptible to framing effects as compared to the other groups included in this study (P ≤ .05, ηp2 = 0.06). In contrast, low-lethality attempters were more susceptible to sunk costs than both the comparison groups and high-lethality attempters (P ≤ .01, ηp2 = 0.09). These group differences remained after accounting for age, global cognitive performance, and impulsive traits. Premorbid IQ partially explained group differences in framing effects.

CONCLUSIONS

Suicide attempters' failure to resist framing may reflect their inability to consider a decision from an objective standpoint in a crisis. Failure of low-lethality attempters to resist sunk cost may reflect their tendency to confuse past and future costs of their behavior, lowering their threshold for acting on suicidal thoughts.

Impulsive traits and unplanned suicide attempts predict exaggerated prefrontal response to angry faces in the elderly

OBJECTIVE

Abnormal responses to social stimuli are seen in people vulnerable to suicidal behavior, indicating possible disruptions in the neural circuitry mediating the interpretation of socioemotional cues. These disruptions have not been empirically related to psychological and cognitive pathways to suicide. In the present study of older suicide attempters, we examined neural responses to emotional faces and their relationship to impulsivity, one of the components of the suicidal diathesis.

METHODS

Using functional magnetic resonance imaging, we recorded neurohemodynamic responses to angry faces in a carefully characterized sample of 18 depressed elderly with history of suicide attempts, 13 depressed nonsuicidal patients, and 18 healthy individuals, all aged 60+. Impulsivity was assessed with the Social Problem Solving Inventory Impulsivity/Carelessness Style subscale and Barratt Impulsiveness Scale. The Suicide Intent Scale planning subscale was used to describe the degree of planning associated with the most lethal attempt.

RESULTS

Depression and history of attempted suicide were not associated with neural responses to angry faces, failing to replicate earlier studies. Higher impulsivity, however, predicted exaggerated responses to angry faces in fronto-opercular and dorsomedial prefrontal cortex (pcorr <0.05). Poorly planned suicide attempts also predicted increased fronto-opercular responses. Results were robust to effects of medication exposure, comorbid anxiety and addiction, severity of depression, burden of physical illness, and possible brain injury from suicide attempts.

CONCLUSION

Impulsive traits and history of unplanned suicide attempts partly explain the heterogeneity in neural responses to angry faces in depressed elderly. Displays of social emotion command excessive cortical processing in impulsive suicide attempters.

Suicide in older adults: the role of emotions and cognition

Suicide in older adults is a significant clinical concern. In this review of recent findings, we concentrate on the role of emotions and cognition in suicide risk and behavior in older adults. We discuss the epidemiology of suicide in older adults, integrate recent findings on non-psychotic major depression, schizophrenia and suicidal ideation, explore the relationship of emotion regulation with suicide, present recent advances on suicide in demented patients, and describe the latest developments on cognition and decision processes in suicide.