Negative mood and optimism bias: An experimental investigation of sadness and belief updating.

BACKGROUND AND OBJECTIVES: Understanding how individuals integrate new information to form beliefs under changing emotional conditions is crucial to describing decision-making processes. Previous research suggests that although most people demonstrate bias toward optimistic appraisals of new information when updating beliefs, individuals with dysphoric psychiatric conditions (e.g., major depression) do not demonstrate this same bias. Despite these findings, limited research has investigated the relationship between affective states and belief updating processes. METHODS: We induced neutral and sad moods in participants and had them complete a belief-updating paradigm by estimating the likelihood of negative future events happening to them, viewing the actual likelihood, and then re-estimating their perceived likelihood. RESULTS: We observed that individuals updated their beliefs more after receiving desirable information relative to undesirable information under neutral conditions. Further, we found that individuals did not demonstrate unrealistic optimism under negative affective conditions. LIMITATIONS: This study incorporated a population of university students under laboratory conditions and would benefit from replication and extension in clinical populations and naturalistic settings. CONCLUSIONS: These findings suggest that momentary fluctuations in mood affect how individuals integrate information to form beliefs.

The associations between sport- and physical activity-related concussions and suicidality, suicide capability, and hopelessness among high school adolescents.

BACKGROUND: Concussions are associated with a variety of physical, cognitive, and mental health impairments. If sustained during adolescence, a time when the brain is undergoing development, the risk of long-term impairments becomes heightened. This is a notable subject for investigation as many concussions are sustained among adolescents during high school sports and other physical activities. METHODS: We used data from the 2019 United States Youth Risk Behavior Survey to investigate the association between concussions and suicidality (i.e., suicide ideation, planning, and attempts), suicide capability (i.e., physical fighting and weapon carrying), and hopelessness, a risk factor for suicide. We utilized a cross-sectional design and used multivariate regression models and t tests for analysis. RESULTS: Participants were 1754 adolescent students who sustained a concussion during the prior year (54.61% male; M age = 15.94) and 9795 adolescent students who did not sustain a concussion during the prior year (47.27% male; M age = 15.95). Females were less likely (13.23%) than males (17.12%) to report at least one concussion in the past 12 months. Both male and female students who had experienced a concussion were more likely to report physical fighting, weapon carrying, and hopelessness. Male students with a concussion history were also more likely to report suicide attempts than male students without a concussion history. CONCLUSION: Findings indicate that concussions are associated with an increased risk of suicide attempts, suicide capability, and hopelessness among male adolescents and suicide capability and hopelessness among female adolescents. They further suggest a need for additional mental health support and safety policies for student-athletes and other at-risk adolescents.

Objective and Subjective Sleep Measures Are Related to Suicidal Ideation and Are Transdiagnostic Features of Major Depressive Disorder and Social Anxiety Disorder.

Suicide is a major public health problem and previous studies in major depression and anxiety show problematic sleep is a risk factor for suicidal ideation (SI). However, less is known about sleep and SI in social anxiety disorder (SAD), despite the pervasiveness of SAD. Therefore, the current study comprised participants with major depressive disorder (MDD) (without comorbid SAD) (n = 26) and participants with SAD (without comorbid MDD) (n = 41). Wrist actigraphy was used to estimate sleep duration, wake after sleep onset, and sleep efficiency; sleep quality was evaluated with self-report. Self-report was also used to examine SI. These measures were submitted to independent t-tests and multiple regression analysis. t-test results revealed sleep and SI did not differ between MDD and SAD groups. Multiple regression results showed shorter sleep duration and worse sleep quality related to greater SI when taking symptom severity and age into account. Post-hoc partial correlational analysis showed these sleep-SI relationships remained significant after controlling for symptom severity and age. Preliminary findings indicate sleep and SI may be transdiagnostic features of MDD and SAD. Evidence of distinct sleep-SI relationships are consistent with previous reports showing that sleep difficulties contribute to SI. Altogether, improving sleep duration and sleep quality may reduce the risk of SI.

Neural responsiveness to reward and suicidal ideation in social anxiety and major depression before and after psychotherapy.

Suicidality is prevalent in Social Anxiety Disorder (SAD) and Major Depressive Disorder (MDD). Limited data indicate the reward positivity (RewP), a neurophysiological index of reward responsivity, and subjective capacity for pleasure may serve as brain and behavioral assays for suicide risk though this has yet to be examined in SAD or MDD in the context of psychotherapy. Therefore, the current study tested whether suicidal ideation (SI) relates to RewP and subjective capacity for anticipatory and consummatory pleasure at baseline and whether Cognitive Behavioral Therapy (CBT) impacts these measures. Participants with SAD (n = 55) or MDD (n = 54) completed a monetary reward task (gains vs. losses) during electroencephalogram (EEG) before being randomized to CBT or supportive therapy (ST), a comparator common factors arm. EEG and SI data were collected at baseline, mid-treatment, and post-treatment; capacity for pleasure was collected at baseline and post-treatment. Baseline results showed participants with SAD or MDD were comparable in SI, RewP, and capacity for pleasure. When controlling for symptom severity, SI negatively corresponded with RewP following gains and SI positively corresponded with RewP following losses at baseline. Yet, SI did not relate to subjective capacity for pleasure. Evidence of a distinct SI-RewP association suggests RewP may serve as a transdiagnositic brain-based marker of SI. Treatment outcome revealed that among participants with SI at baseline, SI significantly decreased regardless of treatment arm; also, consummatory, but not anticipatory, pleasure increased across participants regardless of treatment arm. RewP was stable following treatment, which has been reported in other clinical trial studies.

Risk factors of suicidal behaviors in a high-risk longitudinal veteran sample: A network analysis.

INTRODUCTION: Suicide is a substantial public health burden, particularly among veterans. Risk factors have been delineated for suicide; however, the dynamic interrelations between risk factors have not been fully examined. Such research has the potential to elucidate processes that contribute to suicide risk between individuals with a past suicide attempt (attempters) and those without a past suicide attempt (nonattempters). METHODS: In the current study, network analysis was used to compare networks between attempters and nonattempters in a high-risk veteran sample (N = 770; Mage  = 32.3 years, SD = 6.8; 326 with a past suicide attempt) who were followed over 1 year. Networks were estimated to examine (1) concurrent relations of suicide risk factors at baseline and (2) predictability of prospective suicidal behavior (SB). RESULTS: There were no differences in the overall connectivity of attempter and nonattempter networks. Perceived burdensomeness and posttraumatic stress disorder (PTSD) symptoms were most central in the attempters' network, whereas PTSD symptoms and insomnia were most central in the nonattempters' network. The risk factors prospective SB in either network. However, attempters were more likely to engage in SB over the course of the study. CONCLUSION: These findings highlight the difficulty in predicting who will attempt suicide.

Exploring the indirect effects of acute dissociation on capability and suicide risk: A multi-method investigation with augmented reality.

INTRODUCTION: The current study aimed to explicate the role of dissociation in the capability and suicide relationship by examining how lifetime and state-based acute dissociation contributes to capability for suicide using a multi-method approach of self-report and augmented reality (AR) laboratory tasks. METHOD: Participants (N = 145) were students recruited for course credit at a southern university. Participants completed self-report and laboratory AR dissociative induction tasks. Correlations and mediation analyses were conducted to test hypotheses using SPSS v. 26 and PROCESS Macro. RESULTS: There was a significant indirect effect on capability and suicidal ideation via acute dissociation (ß = 0.035, SE = 0.02, 95% CI = 0.001, 0.095). Additionally, there was a significant indirect effect on capability and suicide attempt(s) via dissociation (ß = 0.19, SE = 0.10, 95% CI = 0.044, 0.449). CONCLUSIONS: As prior theories suggest, dissociation may augment feeling disconnected from the body and may temporarily impact capability to render a suicidal act as more probable. The presence of dissociation after a painful and provocative attempt may increase capability and pain tolerance. Implications of these findings include the consideration of dissociation as a pertinent factor in the assessment and treatment of suicide and the role of AR in aiding the exploration of suicide correlates.

When people die by suicide: Introducing unacceptable loss thresholds as a potential missing link between suicide readiness states and actively suicidal clinical states.

INTRODUCTION: Contemporary models of suicide have largely overlooked why a person at high risk for suicide attempts suicide at a specific time. We propose the construct of unacceptable loss thresholds (i.e., a person's tolerance limit for a negative life event, which if violated results in an increase in suicide risk), which addresses many paradoxes in the literature related to suicide triggers. The aim of this paper is to provide preliminary proof of concept and to stimulate replication and further empirical study. METHODS: We recruited an online community sample of individuals with a suicide attempt history (n = 144). These individuals answered questions about the time leading up to their most recent suicide attempt. RESULTS: The majority (70.8% yes; 18.1% cannot remember; 11.1% no) reported creating a threshold of unacceptable loss, and that relatively small events were enough to trigger feelings that life was not worth living (63.9% yes; 30.6% maybe; 5.6% no). Further, the majority (57.6% yes; 21.5% yes, but only if asked; 20.8% - no) reported they would be willing to tell their therapist/doctor about their thresholds of unacceptable loss. CONCLUSION: The construct of unacceptable loss deserves further empirical inquiry. Individuals contemplating suicide set them and if the loss occurs, it may trigger suicidal action in suicide ready individuals. Thresholds could provide risk assessment and safety planning data currently being overlooked.

Anxiety Sensitivity Index-3 Suicidal Cognition Concerns: A New Measure Examining Negative Reactions to Suicidal Ideation.

OBJECTIVE: Anxiety sensitivity cognitive concerns (ASCC), the fear of the consequences of mental dyscontrol, has been established as a risk factor for suicidal ideation (SI). Treatments targeted at reducing ASCC have been shown to reduce suicide risk. In this study, a new self-report measure, the Anxiety Sensitivity Index-3 Suicidal Cognition Concerns (ASI-3-SCC), was developed to assess sensitivity specifically to thoughts of suicide and wanting to die. METHOD: Participants completed the new measure as well as measures of anxiety sensitivity, depressive symptoms, SI, and worst point SI. We hypothesized that the ASI-3-SCC would be associated with SI and worst point SI. Additionally, we hypothesized that the ASI-3-SCC would moderate the relationship between ASCC and SI. RESULTS: As predicted, the ASI-3-SCC was significantly associated with SI in the past two weeks and lifetime worst point SI after accounting for ASCC and depression. The ASI-3-SCC also moderated the relationship between ASCC and SI such that ASCC was related to SI at high levels of ASI-3-SCC. CONCLUSIONS: We suggest that the interpretation of SI and feelings of wanting to die as dangerous may lead to more attention to those thoughts when they occur and increased psychological distress associated with those thoughts. This measure will allow researchers to measure a novel construct in the literature and further examine the impact of catastrophic interpretations of suicidal thoughts.HighlightsCreated a new measure for sensitivity to thoughts of suicide and wanting to die.Suicidal cognition concerns associated with suicidal ideation in the past two weeks.Suicidal cognition concerns associated with lifetime worst point suicidal ideation.Suicidal cognition concerns moderated AS cognitive concerns and ideation relation.

Comparing symptom networks of daytime and nocturnal panic attacks in a community-based sample.

Nocturnal panic refers to waking in a state of panic without obvious triggers, experiencing the same symptoms as panic attacks that occur while awake. Interrelationships between daytime and nocturnal panic symptoms have not been examined despite theories suggesting panic symptoms perpetuate one another in a forward feedback loop. The current study compared associations between symptoms in daytime and nocturnal panic using network analysis. Network theory conceptualizes symptoms as causing one another, rather than originating from a latent variable (i.e., a disorder). Given that nocturnal panic originates from sleep stages without cognitive activity, cognitive symptoms were expected to be more central in daytime panic networks than nocturnal panic networks. Prior literature indicates similar nocturnal and daytime panic severity; thus, we expected that panic groups would report equivalent panic symptom severity. An online community sample (N = 215) provided panic symptom history. Panic network structures did not differ, although the daytime panic network produced stronger and more numerous connections between physical and cognitive symptoms. The nocturnal panic group, however, reported more severe cognitive symptoms than the daytime panic group. These results challenge biologically-focused nocturnal panic theories and suggest a more significant role of cognitive symptoms in perpetuating nocturnal panic attacks once the individual awakens.

Factors contributing to honor-endorsing men's suicide capability: Firearm ownership, practical capability, and exposure to painful and provocative events.

OBJECTIVE: White men in U.S. cultures of honor die by suicide at greater rates than other demographic groups. This finding has been attributed to factors such as the prevalence and use of firearms in men's suicide in honor states, as well as motivational risk factors (e.g., thwarted belongingness). Other features of honor cultures (e.g., physical aggression, risk-taking behaviors) suggest that honor-endorsing men may frequently experience painful and provocative events (PPEs), which, in turn, may facilitate practical capability for suicide. The present work tested this hypothesis and honor ideology's relationship to firearm ownership and storage practices. METHOD: In two samples of mostly White U.S. men-one undergraduate sample (N = 472, Mage  = 19.76) and one middle- to older adult sample (N = 419, Mage  = 65.17)-we assessed honor ideology endorsement, PPEs, practical capability for suicide, and firearm-related outcomes. RESULTS: Honor endorsement was greater among firearm owners (particularly self-protective owners), but it was unrelated to storage practices. Honor endorsement was positively associated with PPEs and practical capability. Additionally, the relationship between honor ideology and practical capability was indirectly explained by PPE exposure. CONCLUSIONS: Results highlight multiple avenues-PPEs, practical capability for suicide, (self-protective) firearm ownership-by which masculine honor norms may place men at risk for suicide.

Substance use and suicide outcomes among self-injured trauma patients.

BACKGROUND: Research indicates alcohol (AUD) or substance (SUD) use disorders and acute alcohol or drug use serve as risk factors for suicidal behaviors and death both distally and proximally to a suicidal event. However, limited research has investigated these relationships among medically serious suicide attempters at the time of injury without relying on cohorts of substance users only or by examining suicide decedent characteristics. METHODS: Data were collected from the National Trauma Data Bank (NTDB) for 2017. The sample comprised patients who engaged in suicidal and self-injurious acts that were medically serious enough to require trauma admission and were tested for alcohol (N = 9,196) or drug (N = 8,121) exposure upon admission. Logistic regression determined relationships between acute alcohol/substance use, presence of AUDs and SUDs and suicide mortality risk, while linear regression evaluated substance conditions and injury severity and length of stay (LOS). RESULTS: AUDs (OR = 0.59[0.42-0.83]) and SUDs (OR = 0.66[0.48-0.90]) had reduced odds of death but increased LOS (ß = 1.7, p < .001; ß = 0.82, p = .024). Blood alcohol concentration (BAC) was positively associated with reduced odds of death (OR = 0.20[0.06-0.61]), injury severity (ß = -5.3, p < .001), and LOS (ß = -7.5, p < .001). Presence of cocaine (ß = -0.80, p = .044) and opioids (ß = -1.4, p < .001) were associated lower injury severity, while MDMA (ß = 3.6, p = .016) and methamphetamine (ß = 1.5, p = .025) were associated with increased injury severity. CONCLUSIONS: While higher BAC may be associated with lower odds of mortality during a single high-risk suicide event, substance users may be at increased risk for worse outcomes over time. Targeted interventions should be considered to interrupt and develop healthy alternatives for survivors with substance use conditions.

Thwarted belongingness predicts greater neural reactivity to a novel social exclusion image set: Evidence from the late positive potential.

INTRODUCTION: Thwarted belongingness (TB) is among the most well-researched risk factors for suicidal ideation (SI). Yet, there is little research examining neural mechanisms underlying this construct. The present study used a novel social exclusion image set in concert with the late positive potential (LPP) to test the role of neural reactivity social exclusion in TB and SI. METHODS: Participants (n = 243) were recruited based on elevated suicide risk and completed an emotional picture viewing task. The LPP was used to index neural reactivity to a novel set of social exclusion images and international affective picture system (IAPS) neutral, positive, and negative images. RESULTS: Greater TB predicted a larger social exclusion ΔLPP (social exclusion LPP relative to neutral LPP) and social exclusion LPP even when accounting for SI, biological sex, age, negative affect, and perceived burdensomeness. Moreover, the social exclusion LPP was uniquely related to TB beyond the LPP to other images. Last, a larger social exclusion LPP predicted greater SI via elevations in TB. CONCLUSION: Reactivity to social exclusion stimuli may play an important role in SI via elevated TB, but not perceived burdensomeness. Future research should further explore the neural mechanisms underlying other IPT constructs.

Examination of measurement invariance of the Acquired Capability for Suicide Scale.

Capability for suicide is frequently assessed using the Acquired Capability for Suicide Scale (ACSS) or the Acquired Capability for Suicide Scale-Fearlessness About Death (ACSS-FAD); however, the measurement invariance of these self-report measures across relevant demographic groups has not been tested. The current study aimed to examine the measurement invariance of the ACSS and ACSS-FAD across (a) gender; (b) suicide attempt status; and (c) military deployment history in a sample of 2,551 participants (M = 28.92, SD = 10.73; 56.7% male, 68.5% White) who participated in one of several studies funded by the Military Suicide Research Consortium. Results indicated that the ACSS exhibited poor model fit; thus, further investigation of measurement invariance was not conducted. Furthermore, although partial measurement invariance of the ACSS-FAD was met for gender, scalar invariance was not supported across military deployment history, and no form of measurement invariance was met across suicide attempt status. Overall, given the lack of strong model fit and measurement invariance in the ACSS and ACSS-FAD across several demographic groups, new or modified self-report measures for capability for suicide may be warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Contemporary methods in delayed discounting: Applications for suicidology with simulation.

OBJECTIVE: To present an approach for integrating recently developed methods in behavioral economics into suicidology research. At present, existing applications of delay discounting in suicidology have focused predominantly on hypothetical choices related to monetary value as a proxy to "risky" choices linked to unsafe or suicidal behavior. In this report, we outline a more targeted approach that directly indexes choices related to treatment in suicide prevention initiatives and incorporates the strengths afforded by multi-level modeling. This more targeted approach precludes the need for multi-step comparisons (improving power), avoids compressing choice variability across delays into individual values (improving precision), and better accommodates decision-making at the upper and lower extremes (improving reliability). METHOD: We present this analytical approach within the context of a Hypothetical Firearm Decision-making Task with simulated participants. A simulated study is provided to illustrate how this approach can be used to evaluate how individuals make temporally delayed decisions related to treatment for suicidal behavior (i.e., temporarily limiting their access to firearms while undergoing treatment). RESULTS AND CONCLUSIONS: The results of this simulated study are provided to illustrate how more advanced behavioral decision-making models can be used to supplement existing research methods in suicidology.

Editorial overview: Analytic and methodological innovations for suicide-focused research.

This editorial overview provides an introduction to the Suicide and Life-Threatening Behaviors Special Issue: "Analytic and Methodological Innovations for Suicide-Focused Research." We outline several challenges faced by modern suicidologists, such as the need to integrate different analytical and methodological techniques from other fields with the unique data problems in suicide research. Therefore, the overall aim of this issue was to provide up-to-date methodological and analytical guidelines, recommendations, and considerations when conducting suicide-focused research. The articles herein present this information in an accessible way for researchers/clinicians and do not require a comprehensive background in quantitative methods. We introduce the topics covered in this special issue, which include how to conduct power analyses using simulations, work with large data sets, use experimental therapeutics, and choose covariates, as well as open science considerations, decision-making models, ordinal regression, machine learning, network analysis, and measurement considerations. Many of the topics covered in this issue provide step-by-step walkthroughs using worked examples with the accompanied code in free statistical programs (i.e., R). It is our hope that these articles provide suicidologists with valuable information and strategies that can help overcome some of the past limitations of suicide research, and improve the methodological rigor of our field.

Altering preferences for suicide crisis resources using the decoy nudge: Evidence of context-dependent effects in suicide prevention decision making.

OBJECTIVE: Suicide is the 10th leading cause of death in the United States. There are several important decisions that could confer later risk to a suicide attempt (e.g., how to store lethal means). Therefore, understanding how people make decisions that are relevant for suicide risk is an important area of study for suicidology. Human behavior diverges from perfectly rational economic decision making according to observable patterns based on predictable cognitive processes. Nudges attempt to diminish, leverage, or circumvent these deviations to increase the probability of a desired choice being selected or behavior being performed. One deviation from rationality is that human choice is context dependent. This deviation can be observed by introducing an objectively inferior alternative option (a decoy) into a choice array that alters an individual's preference. Using decoys could be one way to nudge people toward best practices in suicide prevention work. METHOD: This study examined if decoys could reliably alter participant preferences for suicide prevention resources using a hypothetical scenario in three separate online samples (i.e., general population, participants with recent suicidal thoughts, gun owners). RESULTS: Our results found that introducing a slightly (but objectively) worse version of an existing suicide prevention resource increased the preference toward the slightly better option. CONCLUSIONS: These findings indicate that using decoys could be an effective nudge for influencing people's preference toward best practices. Most important, these findings highlight the importance of context effects on choice preference in suicide research and prevention efforts, as well as suggest irrational decision-making processes in suicide-relevant decision making. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Time-series analyses of firearm-related Google searches and U.S. suicide rates 2004-2016.

OBJECTIVE: The U.S. suicide rate has increased 35% since 1999. The role of the Internet has not been thoroughly investigated despite Internet use more than doubling from 1999 to present. The majority of U.S. suicide deaths are by firearm; however, there is no examination of the association between trends in firearm Internet searches and overall and firearm monthly suicide rates. We hypothesized that search strings related to firearm suicide would be significantly associated with monthly suicide rates (both all methods and firearm). METHODS: Google Trends provides data on request frequencies of searches. Twenty-four search strings were examined representing possible searches by individuals considering firearm suicide and compared to U.S. suicide rates with time-series modeling. RESULTS: In the time series with higher search volumes, consistent associations were found of negative cross-correlation at lag +1. CONCLUSIONS: Several searches appeared at least sensitive enough to consistently show associations with overall and firearm suicide rates in the following month. This novel finding should be followed up as the potential exists to predict suicide trends.

The Frequency and Subjective Impact of Painful and Provocative Events on the Acquired Capability for Suicide.

BACKGROUND: Leading theoretical explanations for suicide state that for suicide death to occur, a person must have sufficient capability to enact an attempt. Exposure to painful and provocative events is hypothesized to play an important role in acquiring the capability for suicide over a lifetime. Unfortunately, assessment tools for painful and provocative events have focused solely on the frequency of events, neglecting the potential contributions of perceived impact. Further, past measurements have used predetermined items for painful and provocative events thereby neglecting other relevant events. The current study uses visual analog scales (VAS) to assess both the frequency and impact of painful and provocative events and how these contribute to the capability for suicide. METHOD: Data were collected from 787 adults via Amazon's online platform. RESULTS: Findings indicated that the frequency VAS and impact VAS both had a moderate correlation with the original Painful and Provocative Events Scale. Greater scores on the frequency VAS were associated with increased capability, whereas lower scores on the subjective impact VAS were associated with increased capability scores. Both VAS independently predicted capability above and beyond the PPES. LIMITATIONS: Temporal or causal associations are unable to be drawn due to cross-sectional data. In addition, the sample was largely homogenous (White = 72%, female = 63.5%), limiting generalizability. CONCLUSIONS: These initial findings demonstrate individuals who perceive painful and provocative events as being less impactful may have increased capability, and that VAS may be appropriate to approximate the impact and frequency of painful and provocative events.

Suicide attempt survivors' recommendations for improving mental health treatment for attempt survivors.

Research indicates that connection to mental health care services and treatment engagement remain challenges among suicide attempt survivors. One way to improve suicide attempt survivors' experiences with mental health care services is to elicit suggestions directly from attempt survivors regarding how to do so. This study aimed to identify and synthesize suicide attempt survivors' recommendations for how to enhance mental health treatment experiences for attempt survivors. A sample of 329 suicide attempt survivors (81.5% female, 86.0% White/Caucasian, mean age = 35.07 ± 12.18 years) provided responses to an open-ended self-report survey question probing how treatment might be improved for suicide attempt survivors. Responses were analyzed utilizing both qualitative and quantitative techniques. Analyses identified four broad areas in which mental health treatment experiences might be improved for attempt survivors: (a) provider interactions (e.g., by reducing stigma of suicidality, expressing empathy, and using active listening), (b) intake and treatment planning (e.g., by providing a range of treatment options, including nonmedication treatments, and conducting a thorough assessment), (c) treatment delivery (e.g., by addressing root problems, bolstering coping skills, and using trauma-informed care), and (d) structural issues (e.g., by improving access to care and continuity of care). Findings highlight numerous avenues by which health providers might be able to facilitate more positive mental health treatment experiences for suicide attempt survivors. Research is needed to test whether implementing the recommendations offered by attempt survivors in this study might lead to enhanced treatment engagement, retention, and outcomes among suicide attempt survivors at large. (PsycInfo Database Record (c) 2021 APA, all rights reserved).