Entrapment and social problem-solving in suicidal behavior across the adult lifespan.

BACKGROUND: Feelings of entrapment and deficits in social problem-solving skills have been associated with risk for suicidal behavior in the context of depression. However, few studies have examined the effect of age on the association between these risk factors and suicidal behavior across most of the adult lifespan. METHODS: In a three-site study, we tested interactions of age with feelings of entrapment and social problem-solving style in 105 depressed patients with a recent suicide attempt, 95 depressed patients with no history of suicide attempt, and 97 demographically similar non-psychiatric participants (age 16-80). Attempter/non-attempter differences, age interactions, and the relative contribution of entrapment and social problem-solving style to past attempter were examined. RESULTS: Entrapment significantly interacted with age such that it discriminated past attempters from depressed non-attempters better at older ages. Social Problem-Solving Inventory (SPSI) total score and most subscales did not distinguish past attempters, but the SPSI Impulsive Style Problem-Solving was an effective discriminator of past suicide attempts across the full adult lifespan and did not interact with age. In a multipredictor model, both the entrapment by age interaction and SPSI Impulsive Style Problem-Solving score were significant predictors for the classification of attempters. LIMITATIONS: The cross-sectional nature of our research design limited conclusions that may be drawn about individual change over time or cohort effects. CONCLUSIONS: Entrapment did not distinguish past attempters at younger ages but became a better discriminator in middle to late adulthood. An impulsive problem-solving style was associated with past suicide attempts across the full adult lifespan.

A lifetime of challenges: real-life decision outcomes in early- and late-onset suicide attempters.

BACKGROUND: People who have attempted suicide display suboptimal decision-making in the lab. Yet, it remains unclear whether these difficulties tie in with other detrimental outcomes in their lives besides suicidal behavior. We hypothesize that this is more likely the case for individuals who first attempted suicide earlier than later in life. METHODS: A cross-sectional case-control study of 310 adults aged ≥ 50 years (mean: 63.9), compared early- and late-onset attempters (first attempt < 55 vs. ≥ 55 years of age) to suicide ideators, non-suicidal depressed controls and non-psychiatric healthy controls. Participants reported potentially avoidable negative decision outcomes across their lifetime, using the Decision Outcome Inventory (DOI). We employed multi-level modeling to examine group differences overall, and in three factor-analytically derived domains labeled Acting Out, Lack of Future Planning, and Hassles. RESULTS: Psychopathology predicted worse decision outcomes overall, and in the more serious Acting Out and Lack of Future Planning domains, but not in Hassles. Early-onset attempters experienced more negative outcomes than other groups overall, in Lack of Future Planning, and particularly in Acting Out. Late-onset attempters were similar to depressed controls and experienced fewer Acting out outcomes than ideators. LIMITATIONS: The cross-sectional design precluded prospective prediction of attempts. The assessment of negative outcomes may have lacked precision due to recall bias. CONCLUSIONS: Whereas early-onset suicidal behavior is likely the manifestation of long-lasting decision-making deficits in several serious aspects of life, late-onset cases appear to function similarly to non-suicidal depressed adults, suggesting that their attempt originates from a more isolated crisis.

Paralimbic and lateral prefrontal encoding of reward value during intertemporal choice in attempted suicide.

BACKGROUND: Alongside impulsive suicide attempts, clinicians encounter highly premeditated suicidal acts, particularly in older adults. We have previously found that in contrast to the more impulsive suicide attempters' inability to delay gratification, serious and highly planned suicide attempts were associated with greater willingness to wait for larger rewards. This study examined neural underpinnings of intertemporal preference in suicide attempters. We expected that impulsivity and suicide attempts, particularly poorly planned ones, would predict altered paralimbic subjective value representations. We also examined lateral prefrontal and paralimbic correlates of premeditation in suicidal behavior. METHOD: A total of 48 participants aged 46-90 years underwent extensive clinical and cognitive characterization and completed the delay discounting task in the scanner: 26 individuals with major depression (13 with and 13 without history of suicide attempts) and 22 healthy controls. RESULTS: More impulsive individuals displayed greater activation in the precuneus/posterior cingulate cortex (PCC) to value difference favoring the delayed option. Suicide attempts, particularly better-planned ones, were associated with deactivation of the lateral prefrontal cortex (lPFC) in response to value difference favoring the immediate option. Findings were robust to medication exposure, depression severity and possible brain damage from suicide attempts, among other confounders. Finally, in suicide attempters longer reward delays were associated with diminished parahippocampal responses. CONCLUSIONS: Impulsivity was associated with an altered paralimbic (precuneus/PCC) encoding of value difference during intertemporal choice. By contrast, better-planned suicidal acts were associated with altered lPFC representations of value difference. The study provides preliminary evidence of impaired decision processes in both impulsive and premeditated suicidal behavior.

Corticostriatothalamic reward prediction error signals and executive control in late-life depression.

BACKGROUND: Altered corticostriatothalamic encoding of reinforcement is a core feature of depression. Here we examine reinforcement learning in late-life depression in the theoretical framework of the vascular depression hypothesis. This hypothesis attributes the co-occurrence of late-life depression and poor executive control to prefrontal/cingulate disconnection by vascular lesions. METHOD: Our fMRI study compared 31 patients aged ⩾60 years with major depression to 16 controls. Using a computational model, we estimated neural and behavioral responses to reinforcement in an uncertain, changing environment (probabilistic reversal learning). RESULTS: Poor executive control and depression each explained distinct variance in corticostriatothalamic response to unexpected rewards. Depression, but not poor executive control, predicted disrupted functional connectivity between the striatum and prefrontal cortex. White-matter hyperintensities predicted diminished corticostriatothalamic responses to reinforcement, but did not mediate effects of depression or executive control. In two independent samples, poor executive control predicted a failure to persist with rewarded actions, an effect distinct from depressive oversensitivity to punishment. The findings were unchanged in a subsample of participants with vascular disease. Results were robust to effects of confounders including psychiatric comorbidities, physical illness, depressive severity, and psychotropic exposure. CONCLUSIONS: Contrary to the predictions of the vascular depression hypothesis, altered encoding of rewards in late-life depression is dissociable from impaired contingency learning associated with poor executive control. Functional connectivity and behavioral analyses point to a disruption of ascending mesostriatocortical reward signals in late-life depression and a failure of cortical contingency encoding in elderly with poor executive control.

The temptation of suicide: striatal gray matter, discounting of delayed rewards, and suicide attempts in late-life depression.

BACKGROUND: Converging evidence implicates basal ganglia alterations in impulsivity and suicidal behavior. For example, D2/D3 agonists and subthalamic nucleus stimulation in Parkinson's disease (PD) trigger impulse control disorders and possibly suicidal behavior. Furthermore, suicidal behavior has been associated with structural basal ganglia abnormalities. Finally, low-lethality, unplanned suicide attempts are associated with increased discounting of delayed rewards, a behavior dependent upon the striatum. Thus, we tested whether, in late-life depression, changes in the basal ganglia were associated with suicide attempts and with increased delay discounting. METHOD: Fifty-two persons aged ≥ 60 years underwent extensive clinical and cognitive characterization: 33 with major depression [13 suicide attempters (SA), 20 non-suicidal depressed elderly] and 19 non-depressed controls. Participants had high-resolution T1-weighted magnetization prepared rapid acquisition gradient-echo (MPRAGE) magnetic resonance imaging (MRI) scans. Basal ganglia gray matter voxel counts were estimated using atlas-based segmentation, with a highly deformable automated algorithm. Discounting of delayed rewards was assessed using the Monetary Choice Questionnaire (MCQ) and delay aversion with the Cambridge Gamble Task (CGT). RESULTS: SA had lower putamen but not caudate or pallidum gray matter voxel counts, compared to the control groups. This difference persisted after accounting for substance use disorders and possible brain injury from suicide attempts. SA with lower putamen gray matter voxel counts displayed higher delay discounting but not delay aversion. Secondary analyses revealed that SA had lower voxel counts in associative and ventral but not sensorimotor striatum. CONCLUSIONS: Our findings, although limited by small sample size and the case-control design, suggest that striatal lesions could contribute to suicidal behavior by increasing impulsivity.

Treatment outcome in suicidal vs. non-suicidal elderly patients.

The authors investigated treatment outcome in elderly suicidal and non-suicidal patients with recurrent major depression. Patients without suicidal ideation in the current episode (Non-Ideators; n=150) were compared with 30 patients who expressed suicidal ideation (Ideators). Patients received combined pharmacotherapy and psychotherapy during acute and continuation treatment. Ideators had higher numbers of lifetime suicide attempts and reported significantly higher levels of depression, anxiety, and hopelessness before starting treatment. Ideators and Non-Ideators had almost identical remission rates (77% vs. 78%), but Ideators had higher relapse rates during continuation treatment (26% vs. 13%) and were more likely to receive augmentation pharmacotherapy. Anxiety and use of adjunctive medication, but not suicidal ideation, were negatively related to both remission and relapse. Our data suggest that elderly suicidal patients have an overall favorable treatment outcome. However, treatment response may be more brittle and may require the continuing use of adjunctive medications to prevent early relapse.

High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide.

OBJECTIVE: To determine whether a high level of hopelessness after treatment of a depressive episode is an indicator of a history of lifetime suicide attempts in older people. DESIGN: Groups of suicide attempters, suicidal ideators, and nonsuicidal patients were compared via analysis of variance with respect to levels of hopelessness, depression, anxiety, and global functioning before and after treatment of depression. SETTING: An outpatient research clinic providing two treatment protocols of late-life mood disorders. PARTICIPANTS: A total of 107 consecutive outpatients (mean age 67) with major depression who responded to treatment. MEASUREMENTS: Levels of hopelessness, severity of depression, anxiety, and global functioning were compared across the three groups at the beginning of treatment and at remission. RESULTS: After remission there were no differences between the three groups in depression severity, anxiety, and global functioning. Hopelessness remained significantly higher in the attempter group than among ideators or nonsuicidal patients. CONCLUSIONS: Suicide attempts, the most important risk factor for subsequent suicide, are associated with persistent, high levels of hopelessness following remission of depression in late-life patients. These findings suggest that treatments designed specifically to lower hopelessness (such as cognitive, behavioral or interpersonal therapy) may be effective in reducing suicide risk.

Suicidal ideation in elderly bereaved: the role of complicated grief.

This study examined whether symptoms of complicated grief at baseline predicted suicidal ideation during a depressive episode in elderly bereaved individuals. Over a 17-month period, serial ratings of suicidal ideation, hopelessness, and symptoms of depression, anxiety, and complicated grief were obtained from 130 elderly participants who had lost their spouses within the past 2 years. Groups of active and passive suicidal ideators, as well as nonideator controls, were compared via analysis of variance (ANOVA) with respect to levels of complicated grief, depression, and anxiety. Elderly bereaved with both active and passive suicidal ideation were found to have higher symptomatic levels of depression, hopelessness, complicated grief, and anxiety, as well as lower levels of perceived social support, than nonideators at study entry. Fifty-seven percent of the patients with high complicated grief scores were found to be ideators during the follow-up versus 24% of the patients with low complicated grief scores. Patients with any suicidal ideation had higher symptom levels of depression, anxiety, and complicated grief when they were ideators as compared with periods when they denied ideation. Fifteen out of the 39 ideators had recurrent depressive episodes versus 5 of the 91 nonideators. Patients with a history of suicide attempts were more likely to be ideators after loss than other bereaved. Thus, the condition of having high levels of complicated grief symptoms and depressive symptoms appears to make bereaved individuals vulnerable to suicidal ideation. Detection of high levels of complicated grief could help clinicians identify patients who may be at heightened risk for suicide.

Clinical assessment versus research methods in the assessment of suicidal behavior.

OBJECTIVE: This study examined how accurately routine inpatient clinical assessments documented a history of overt suicidal behavior in inpatients with a diagnosis of major depressive episode. Secondary questions involved the exploration of possible factors influencing the quality of routine clinical documentation of suicidal behavior, such as lethality of attempts, axis II comorbidity, and presence of recent suicidal behavior. METHOD: Hospital records for 50 patients, known to have a history of suicidal behavior on the basis of research ratings, were reviewed to assess reporting of the number of lifetime suicide attempts, suicidal ideation and planning behavior, most medically lethal suicide attempt, and family history of suicidal behavior. These measures of suicidal behavior were compared with a comprehensive research assessment, completed concurrently and independently. RESULTS: At admission clinicians failed to document a history of suicidal behavior in 12 of 50 patients identified by research assessment as depressed and as having attempted suicide. Fewer total suicide attempts were clinically reported than in research data. Documentation of suicidal behavior was least accurate in the physician discharge summary and was most accurate on hospital intake assessment, which employed a semistructured format for recording clinical information including suicidal behavior. CONCLUSIONS: A significant degree of past suicidal behavior is not recorded during routine clinical assessment, and the use of semistructured screening instruments may improve documentation and detection of lifetime suicidal behavior. The physician discharge summary must accurately document suicidal behavior, since it best identified a high-risk population for out-patient clinicians responsible for follow-up.