Neurocognitive vulnerability to youth suicidal behavior
Introduction
The suicide rate among youth aged 10–24 years in the United States has increased by 47% between 2009 and 2018, and is the second leading cause of death in this age group (Centers for Disease Control and Prevention, 2020a, 2020b). A history of suicide attempt is the strongest predictor of youth suicide and up to 90% of young suicide decedents have a psychiatric disorder at time of death, most commonly major depressive disorder (MDD) (Bridge et al., 2006; Hawton et al., 1998; Shaffer et al., 1996). However, most youth with MDD never attempt suicide, diminishing the positive predictive value of a diagnosis of MDD in gauging the risk of future suicidal behavior. The severe consequences of early-onset suicide attempt make the identification of youth at high risk an important clinical and research goal (Goldsmith et al., 2002). Efforts to prevent youth suicide would benefit from a deeper understanding of factors associated with suicidal behavior in youth with MDD to identify depressed youth at greatest risk for making an initial suicide attempt, and to intervene and preempt suicidal behavior. Such knowledge can also inform the development of effective evaluation and intervention strategies designed to target specific risk factors for suicide in clinically depressed youth.
Neurocognitive dysfunction is one factor that may influence the risk of suicidal behavior in the context of MDD. Recent meta-analyses of neurocognitive vulnerability to suicidal behavior in individuals with mood disorders revealed greater impairments in value-based and cognitive control processes among suicide attempters relative to depressed non-attempters and non-suicidal controls (Richard-Devantoy et al., 2012, 2014). Similarly, a meta-analysis examining the association between memory deficits and suicidal behavior found greater impairments in long-term memory, autobiographical memory, and working memory among suicide attempters compared with patient and healthy controls (Richard-Devantoy et al., 2015). Notably, of the 58 studies included in these meta-analyses (Richard-Devantoy et al., 2012, 2014, 2015), only 3 studies (Arie et al., 2008; Bridge et al., 2012; Oldershaw et al., 2009) included adolescent-only samples; of these, one study (Oldershaw et al., 2009) focused on deliberate self-harm (i.e., self-injurious behavior that may or may not include suicidal intent), which may have neurocognitive correlates distinct from those associated with suicide attempts. Similar to findings in adults, Arie et al. (2008) found youth with a history of suicide attempts had more difficulties with autobiographical memory compared to controls, while Bridge et al. (2018) revealed a significant association between impaired decision making and attempted suicide in youth.
Neurocognitive studies of adults with depression have also shown more severe executive function and decision-making deficits in suicide attempters with current suicidal ideation than past attempters without suicidal ideation and healthy controls (Westheide et al., 2008). Marzuk et al. (2005) found depressed suicidal adults, in comparison with depressed non-suicidal adults, performed significantly worse on several measures of executive performance associated with prefrontal regions of the brain, but the groups were similar on measures tapping non-frontal brain regions. Additional studies with adults have examined neurocognitive functioning and future suicidal behavior (Cha et al., 2010; Nock et al., 2010). In one study, attentional bias towards suicide-related stimuli, compared to other negatively valanced and neutral stimuli, was reported to be significantly associated with future suicide attempts even after controlling for previous suicidal behavior and clinical predictors (Cha et al., 2010). In a test of implicit association, Nock and colleagues found participants who self-identified with constructs representing death and suicide were 6 times more likely to make a subsequent suicide attempt (Nock et al., 2010). To the best of our knowledge, no similar studies have been conducted in adolescents with mood disorders or that have examined sex-specific associations between suicidal behavior and neurocognitive functioning.
The aim of the current study was to investigate neurocognitive function in three groups of adolescents with a lifetime history of MDD: 1) those with a history of suicide attempt, 2) those with a history of suicidal ideation but no history of a suicide attempt, and 3) those with no history of suicidal ideation or suicide attempt. We hypothesized that adolescents with a history of suicide attempt would display more neurocognitive deficits than those with suicidal ideation and no history of suicidal ideation or attempt, and that suicidal ideators would display poor neurocognitive function relative to never-suicidal participants. The moderating effect of sex on the association between group status and neurocognitive function was also evaluated, and we expected group differences to persist after controlling for demographic and clinical risk factors. An exploratory aim was to examine if baseline neurocognitive functioning prospectively predicted suicide attempts during the two-year follow-up.
Section snippets
Sample
A convenience sample was recruited from a large metropolitan children's hospital and affiliated community behavioral health clinics. Eligible youth (N = 724) were those who screened positive for depressive symptoms using an adapted version of the Patient Health Questionnaire for Adolescents (PHQ-A) (Johnson et al., 2002) and whose parents or legal guardians agreed to be contacted about potential research opportunities. To be considered for the study, all youth had to have at least one parent or
Demographic and clinical comparisons
The study sample was 69% female, with a mean age of 13.83 (SD = 1.04) at the index date. The self-identifying racial/ethnic composition was predominantly white (62%), with 28% black, 10% other race, and 9% Hispanic or Latino participants. Suicide attempters made their first attempt around the age of 12 years (M = 12.40, SD = 2.01, range: 5–15 years). Roughly half made multiple suicide attempts (42%) with maximum self-reported suicidal intent in the moderate severity range with a mean of 4.5 out
Discussion
To our knowledge, this is the first study to identify sex-specific differences in neurocognitive functioning among adolescents with a lifetime diagnosis of MDD and differing history of suicidal ideation and suicide attempt. We also identified prospective neurocognitive predictors of suicide attempts. Neurocognitive domains associated with affective bias in females and spatial working memory in males were found to be significantly different between groups that differed by ideation or attempt
Author statement
Drs Ruch, Sheftall, and Bridge along with Heck, McBee-Strayer, and Tissue had full access to all data in the study and take responsibility for the acquisition, integrity, and accuracy of the data. Drs Ruch and Bridge conducted statistical analyses. Drs Ruch, Sheftall, Reynolds, Ackerman, Brent, Campo, and Bridge were responsible for the study concept and design. All authors provided critical feedback with respect to the content and critical revision of the manuscript.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
This work was supported by a grant from the National Institutes of Health, National Institute of Mental Health [grant number R01-MH093552]. The Extramural Division of the National Institute of Mental Health did not participate in the design and conduct of the study, in the collection, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript.
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