We aim to identify distinct pathways to suicidal behavior with special interest in medically serious, “failed” suicide attempts that most closely resemble death by suicide. In almost all countries of the world that report statistics on suicide, suicide rate is highest in old age. Old age suicide attempts are characterized by high intent and high medical lethality, providing the best in-vivo window into death by suicide. Medical seriousness (high- and low-lethality attempts) seems to reflect distinct biological vulnerabilities, conferring different risk profiles.
Lab News
In February 2024 Emma O'Brien presented her first-author poster on personality profiles in older adult suicide attempters to the Society for Personality and Social Psychology Conference in San Diego, CA. Emma's poster describes an analysis that found three distinct personality profiles of older adults who have attempted suicide. Results show that extraverted rigid attempters were older at the time of their first suicide attempt and at the time of their most recent suicide attempt compared to other attempter groups. Moreover, extraverted rigid and callous narcissistic attempters had more cognitive deficits than introverted labile attempters and non-attempters. In addition, introverted labile attempters had higher borderline traits among all groups which aligns with prior research demonstrating the wide overlap between borderline traits and high neuroticism-low extraversion.
The article entitled “Is late-onset suicidal behavior a distinct subtype?" suggests consideration of at least two distinct pathways to suicidal behavior in late life based on when the first suicidal crisis occurred. We summarize available evidence so far on early-onset and late-onset attempters, and the potential heterogeneity in the interplay of risk/precipitating factors. Our research indicates that familial/social exposure to suicidal behavior, childhood trauma, impulsivity, neuroticism, Cluster B traits, longstanding interpersonal difficulties, and real-life suboptimal decision patterns are found predominantly in attempters experiencing their first suicidal crisis between youth and early midlife. In contrast, broader cognitive deficits and distinct personality traits (such as high conscientiousness) are characteristic of late-onset suicide attempters.
Two of our team members, Emma O'Brien and Ashlie Gariepy, recently participated in the Out of Darkness Walk, a fundraiser by the American Foundation for Suicide Prevention.
Our Co-I, Dr. Hanga Galfalvy and collaborator, Dr. Anna Szücs, recently presented at the 2023 Society of Biological Psychiatry (SOBP) annual conference.
Multi-domain data explain suicide attempter status and age at first attempt in depressed middle aged and older adults using penalized regression methods [Poster presentation]. Galfalvy, H., Szücs, A., Xu, Y., Campbell, E., & Szanto, K. (2023, April 27-29). Society of Biological Psychiatry, San Diego, CA, U.S.
Are carefully planned suicide attempts more lethal? Effect of age of onset on the relationship between planning and suicide attempt lethality [Poster presentation].Falconi, M. (2023, April 27-29). Society of Biological Psychiatry, San Diego, CA, U.S.
Diligent for better or worse: trait conscientiousness in suicidal ideation and behavior and its moderating effect on ageing-related stressors [Poster presentation].Szücs, A., Galfalvy, H., Alessi, M., Kenneally, L., Valderas, J., Maier, A, & Szanto, K. (2023, April 27-29). Society of Biological Psychiatry, San Diego, CA, U.S.
Social connectedness and physical comorbidities moderate the effect of depression severity on suicidal ideation in older adults [Poster presentation].Galfalvy, H., Szücs, A., Wang, Q., Stoms, M., & Szanto, K. (2023, April 27-29). Society of Biological Psychiatry, San Diego, CA, U.S.
Most studies do not consider the heterogeneity of suicide attempters and age-specific suicide risk factors. We found that those elderly whose first suicide attempt occurred during adolescence or young adulthood had differences in personality traits, cognitive performance, real-life decision making, and familial and social transmission of suicide than late-onset suicide attempters. We found that some of the suicide risk factors mark life-long vulnerabilities and help to understand pathways to suicidal behavior across the life span, while some are age-specific, and hinder adaptation to age-related stressors. For example, we found that only early-onset suicide attempters exhibited significantly higher levels of neuroticism, introversion, and cluster B traits than those who first attempt suicide in late life. In addition, only early-onset, but not late-onset, suicide attempters had higher levels of familial and social transmission of suicidal behavior compared to non-suicidal depressed elderly. Our studies also showed that late-onset suicidal behavior is associated with a broad range of cognitive deficits, including memory, processing speed, and executive dysfunction, possibly signaling a dementia prodrome. In contrast, both early-onset and late-onset suicide attempters display impairment in cognitive control (including conflict monitoring and cognitive flexibility). These cognitive impairments are unique among suicidal elderly and not merely the results of being in a depressive state. These studies have also shown that cognitive control deficits are most likely biomarkers for the suicidal diathesis as they persist across the course of illness.
Late-onset suicide: A dementia prodrome?Gujral, S., Butters, M. A., Dombrovski, A. Y., & Szántó, K. (2021).The American Journal of Geriatric Psychiatry, 29(7), 709-713. https://doi.org/10.1016/j.jagp.2020.12.004
It has been highly debated whether or not suicide prevention is even possible. Dr. Szántó has conducted a successful educational suicide prevention program for GPs and their nurses in rural Hungary, one of the highest suicide rate regions of the world. This program, together with the establishment of a depression treatment clinic and a psychiatric telephone consultation program, helped reduce the suicide rate by 16% over 5 years. This change was significantly higher than the rate of change in the control region and the rate in the country as a whole. By using the psychological autopsy method, we identified common modifiable flaws in the treatment of suicidal patients who received combined psychotherapy and medication management preceding their suicide.
Dr. Szántó’s investigative focus is the psychopathology, treatment, and prevention of suicidal behavior, with a special focus on geriatric suicide. Her studies showed that in an acute depressive episode, treatment of depression is necessary but not sufficient to treat suicidal elderly. Suicidal older adults needed twice as long to get well and had significantly lower response rates than non-suicidal elderly when treated with tricyclics or an SSRI with or without interpersonal psychotherapy.
People who attempt suicide make poor decisions in other contexts. Using a behavioral economics approach we study how individual differences in decision-making relate to suicide risk. Our lab was the first to show probabilistic reversal learning deficits in suicide attempters. This finding prompted our subsequent investigations on how suicide attempters make decisions in complex/ambiguous environments incorporating probability, time, and social context into decisions. We also investigate how certain personality styles (i.e. satisfizing or maximizing, proneness to regret) and cognitive impairments relate to decision competence, real-life decision making, and suicidal behavior.
Decision-making Competence and Attempted Suicide.
Szántó, K., Bruine de Bruin, W., Parker, A., Hallquist, M., Vanyukov, P. M., & Dombrovski, A. Y. (2015). Journal of Clinical Psychiatry. 77(9), 76.
Traditional risk factors for suicide poorly distinguish between suicide ideators and suicide attempters and do not take into consideration the heterogeneity of suicidal behavior. Using neurocognitive assessments, game theory experiments, and decision process measures, Dr. Szántó’s studies so far have contributed to the development of a specific stress-diathesis model of suicidal behavior in late-life and have helped to identify potentially modifiable risk factors. Drs. Dombrovski and Szántó were the first to show probabilistic reversal learning deficits in suicide attempters. This finding prompted subsequent investigations into how suicide attempters make decisions in complex/ambiguous environments incorporating probability, time, and social context into decisions. Dr. Szántó’s training in behavioral economics has provided new tools and insights into individual differences in decision competence and negative life decision outcomes. She investigated how certain personality styles (i.e. satisficing or maximizing, and/or proneness to regret) and cognitive impairments relate to decision competence and late-life suicidal behavior, measured older suicide attempters’ ability to recognize complex social emotions and their responses to perceived unfairness using an economic exchange game, and uncovered in older suicide attempters a failure to integrate the emotional response to social inequity with anticipated personal gain/loss.
Interpersonal problems can trigger suicide while social support can be protective; however, the link between these factors is complicated. Most of the well-known suicide risk factors such as hopelessness and feelings of lack-of-belonging contribute to contemplation of suicide but are not specific to or more exaggerated in those who act on their suicidal thoughts. Moreover, Dr. Szántó’s studies found that early-onset, mostly low-lethality attempts were associated with poor interpersonal functioning and cluster B traits.
