Neural correlates of deceased-related attention during acute grief in suicide-related bereavement.

BACKGROUND: Individuals who have lost a loved one to suicide demonstrate an attentional bias to deceased-related stimuli during early grief. Regulating attention toward reminders of the deceased during acute bereavement may be linked to grief trajectory and pathological grief development. Despite the potential prognostic importance, little is known about underlying neural circuitry correlates of deceased-related grief processing. The current study examines neural substrates of deceased-related attentional processing during acute grief in individuals bereaved by suicide. METHODS: Thirty-seven participants grieving the loss of a first-degree relative or partner to suicide in the prior six months, underwent functional magnetic resonance imaging (fMRI) while performing an emotional Stroop task using words related to the deceased and a living attachment figure, in order to examine neural correlates of deceased-specific attentional processing. Clinical interviews were conducted at baseline. RESULTS: Deceased-related attentional bias was associated with blood oxygen level-dependent (BOLD) activation in a brain network, including dorsolateral prefrontal cortex (dlPFC), ventrolateral prefrontal cortex (vlPFC), orbitofrontal cortex (OFC), and insula. Greater activation of a bilateral prefrontal cluster during deceased-specific attention was negatively correlated with self-reported grief avoidance behaviors. LIMITATIONS: Lack of non-suicide grief control and small sample size. CONCLUSIONS: These data, if confirmed, indicate a neural network specific to deceased-related attention, and that cognitive control regions within this network appear to be related to grief avoidance behaviors during acute bereavement.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review.

Objective: The authors sought to identify scalable evidence-based suicide prevention strategies. Methods: A search of PubMed and Google Scholar identi- fied 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment. Results: Training primary care physicians in depression rec- ognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active out- reach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are under-studied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides. Conclusions: Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physi- cian settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.Reprinted from Am J Psychiatry 2021; 178:611-624, with permission from American Psychiatric Association Publishing. Copyright © 2021.

Attentional bias during acute grief predicts clinical outcome in suicide-related bereavement.

BACKGROUND: Individuals who have lost a loved one to suicide are at increased risk for developing complicated grief (CG). It is unclear why only a subgroup of bereaved develops pathological forms of grief. Vulnerability may be related to the ability to regulate attention toward reminders of the deceased during the acute phase of grief. Using a longitudinal design, we determined whether loss-related attentional bias during acute grief predicts grief severity one year later. METHODS: Thirty-seven participants grieving a first-degree relative or partner to suicide in the prior 6 months performed an emotional Stroop task using words related to the deceased, a living attachment figure, living non-attachment figure, and color congruent Stroop to quantify related attentional bias during the acute grief period. Clinical interviews were conducted at baseline (N = 37) and one year later (N = 35). RESULTS: Participants showed greater attentional bias to deceased-related word trials compared with living attachment, non-attachment, and congruent trials, controlling for age, time since loss, depression, and psychiatric medication. A greater reduction in grief severity over time was associated with more deceased-related attentional bias at baseline. Self-reported grief avoidance was related to deceased-related attentional bias, with lower avoidance scores associated with greater bias. LIMITATIONS: Lack of non-suicide grief control and small sample size. CONCLUSIONS: Less deceased-related bias following the loss may hinder the transition from acute to integrated grief and result in poorer grief trajectories.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review.

OBJECTIVE: The authors sought to identify scalable evidence-based suicide prevention strategies. METHODS: A search of PubMed and Google Scholar identified 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment. RESULTS: Training primary care physicians in depression recognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are understudied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides. CONCLUSIONS: Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physician settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.

Suicidal subtypes, stress responsivity and impulsive aggression.

While prominent models of suicidal behavior emphasize the hypothalamic- pituitary-adrenal (HPA) axis dysregulation, studies examining its role have yielded contradictory results. One possible explanation is that suicide attempters are a heterogeneous group and HPA axis dysregulation plays a more important role only in a subset of suicidal individuals. HPA axis dysregulation also plays a role in impulsivity and aggression. We hypothesize subgroups of attempters, based on levels of impulsivity and aggression, will differ in HPA axis dysregulation. We examined baseline cortisol, total cortisol output, and cortisol reactivity in mood disordered suicide attempters (N = 35) and non-attempters (N = 37) during the Trier Social Stress Test. Suicide attempters were divided into four subgroups: low aggression/low impulsivity, high aggression/low impulsivity, low aggression/high impulsivity, and high aggression/high impulsivity. As hypothesized, attempters and non-attempters did not differ in any cortisol measures while stress response differed based on impulsivity/aggression levels in suicide attempters, and when compared to non-attempters. Specifically, attempters with high impulsive aggression had a more pronounced cortisol response compared with other groups. This is the first study to examine the relationship between cortisol response and suicidal behavior in impulsive aggressive subgroups of attempters. These findings may help to identify a stress responsive suicidal subtype of individuals.

Attentional Bias to Reminders of the Deceased as Compared With a Living Attachment in Grieving.

BACKGROUND: Grieving individuals demonstrate attentional bias toward reminders of the deceased versus neutral stimuli. We sought to assess bias toward reminders of the deceased versus a living attachment figure and to evaluate similarities and differences in the neural correlates of deceased- and living-related attention. We also sought to identify grief process variables associated with deceased-related attentional bias. METHODS: Twenty-five subjects grieving the death of a first-degree relative or partner within 14 months performed an emotional Stroop task, using words related to a deceased or a living attachment figure, and a standard Stroop task, to identify general selective attention, during functional magnetic resonance imaging. Subjects rated word sadness, complicated grief symptoms, depression severity, attachment style, emotional pain, nonacceptance, yearning, and intrusions. RESULTS: We identified an attentional bias to deceased-related versus living-related words, independent of age, depression severity/history, loss type, word sadness, medication use, and time since loss. Attentional bias correlated with complicated grief severity and intrusive thinking. A conjunction analysis identified joint activation in the fusiform gyrus, posterior cingulate, and temporal parietal junction across living- and deceased-related attention versus general selective attention. Insecure-avoidant attachment style correlated with decreased engagement of this network in deceased-related attention. CONCLUSIONS: We have demonstrated an attentional bias to reminders of the deceased versus a living attachment in grieving. Overlapping neural circuits related to living- and deceased-related attention suggest that the bereaved employ similar processes in attending to the deceased as they do in attending to the living. Deceased-related attentional bias appears to be linked primarily to intrusive thinking about the loss.

Prevention of Firearm Suicide in the United States: What Works and What Is Possible.

OBJECTIVE: About 21,000 suicides in the United States in 2014 involved a firearm. The authors reviewed evidence from around the world regarding the relationship between firearm ownership rates and firearm suicide rates and the potential effectiveness of policy-based strategies for preventing firearm suicides in the United States. METHOD: Relevant publications were identified by searches of PubMed, PsycINFO, MEDLINE, and Google Scholar from 1980 to September 2015, using the search terms suicide AND firearms OR guns. Excluding duplicates, 1,687 results were found, 60 of which were selected for inclusion; these sources yielded an additional 10 studies, for a total of 70 studies. RESULTS: Case-control and ecological studies investigating geographic and temporal variations in firearm ownership and firearm suicide rates indicate that greater firearm availability is associated with higher firearm suicide rates. Time-series analyses, mostly from other countries, show that legislation reducing firearm ownership lowers firearm suicide rates. Because the Second Amendment curtails legislation broadly restricting firearm access in the United States, the emphasis is shifted to restricting access for those at risk of harming themselves or others. Most suicides involve guns purchased years earlier. Targeted initiatives like gun violence restraining orders, smart gun technology, and gun safety education campaigns potentially reduce access to already purchased firearms by suicidal individuals. Such measures are too new to have evidence of effectiveness. CONCLUSIONS: Broadly reducing availability and access to firearms has lowered firearm suicide rates in other countries but does not appear feasible in the United States. Approaches restricting access of at-risk individuals to already purchased firearms by engaging the public and major stakeholders require urgent implementation and outcome evaluation for firearm suicide prevention.