Laura S. van Velzen

Suicidal mental imagery—vivid, intrusive mental images of suicide or death—is common among young people experiencing suicidal ideation and may increase risk of suicidal behaviour, yet interventions directly targeting these images are limited. We conducted a single-arm pilot study evaluating the feasibility, acceptability and safety of a brief, therapist-delivered imagery rescripting intervention targeting action-facilitating suicidal mental imagery in help-seeking young people aged 16–25 years with mood disorders and current or recent suicidal ideation. Fifteen participants were recruited; 12 were eligible for the intervention and 11 (92%) completed treatment and follow-up. The recruitment target (N = 25) was not met, largely due to service disruptions and clinician capacity constraints. Acceptability and safety criteria were met: 73% reported that sessions were not distressing, none felt less safe following treatment, and no participant showed increased suicidal ideation from baseline to follow-up. Two serious adverse events occurred but were judged unrelated to the intervention. Exploratory analyses showed reductions in suicidal-image frequency, realness, compellingness, intrusiveness and distress, alongside a 62.5% reduction in suicidal ideation severity. Our pilot study provides preliminary indications that directly rescripting action-facilitating suicidal mental imagery showed encouraging short-term safety and acceptability signals in young people, supporting evaluation in a larger randomised controlled trial.

Suicidal mental imagery – vivid, intrusive mental images of suicide or death - is common among young people experiencing suicidal ideation and may increase risk of suicidal behaviour, yet interventions directly targeting these images are lacking. We conducted a single-arm pilot study evaluating the feasibility, acceptability and safety of a brief, therapist delivered imagery rescripting intervention targeting action-facilitating suicidal mental imagery in help-seeking young people aged 16–25 years with mood disorders and current or recent suicidal ideation. Fourteen participants were recruited; 12 were eligible for the intervention and 11 (92%) completed treatment and follow-up. The recruitment target (N=25) was not met, largely due to service disruptions and clinician capacity constraints. Acceptability and safety criteria were met: 73% reported that sessions were not distressing, none felt less safe following treatment, and no participant showed increased suicidal ideation from baseline to follow-up. Two serious adverse events occurred but were judged unrelated to the intervention. Exploratory analyses showed reductions in suicidal-image frequency, realness, compellingness, intrusiveness and distress, alongside a 52% reduction in suicidal ideation severity. Our pilot study indicates that directly rescripting action-facilitating suicidal mental imagery showed encouraging short-term safety and acceptability signals in young people, supporting evaluation in a larger randomised controlled trial.

The understanding of how antidepressant (AD) use is associated with brain structure in individuals with major depressive disorder (MDD) remains incomplete. We aimed to examine the association between AD medication use and brain morphology in relation to age and sex by pooling structural neuroimaging and clinical data from 32 cohorts within the ENIGMA-MDD working group. Interaction effects of group (2076 cases with current AD use (AD), 1495 cases not currently taking AD (nAD) and 5125 healthy controls (HC)) with age and sex, and main effects of group on regional brain structure (cortical surface area and thickness, and subcortical volume) were examined. Additionally, we examined the effect of AD type (SSRI, SNRI or mirtazapine) and duration of use on brain morphology. Younger individuals in the AD group showed lower bilateral middle temporal gyrus thickness compared to nAD and HC, but this was not seen in older individuals (crossover around 50 years). Lower hippocampal volume and thinner inferior temporal gyrus were shown in AD compared to nAD. These effects were independent of group differences in disease-course-related measures, but were driven by depressive symptom severity. Greater bilateral rostral anterior cingulate thickness was found in individuals older than approximately 40 years taking mirtazapine compared to individuals taking SSRIs or SNRIs. Evidence for subtle structural brain differences in temporal and limbic regions in individuals with MDD who currently use AD medication were found compared to those not currently taking AD medication. Future longitudinal studies are needed to determine the causality of these associations.

Previous studies have suggested that alterations in white matter (WM) microstructure are implicated in suicidal thoughts and behaviours (STBs). However, findings of diffusion tensor imaging (DTI) studies have been inconsistent. In this large-scale mega-analysis conducted by the ENIGMA Suicidal Thoughts and Behaviours (ENIGMA-STB) consortium, we examined WM alterations associated with STBs. Data processing was standardised across sites, and resulting WM microstructure measures (fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity and radial diffusivity) for 24 WM tracts and one global measure were pooled across 40 cohorts. We compared these measures among individuals with a psychiatric diagnosis and lifetime history of suicide attempt ( n = 652; mean age = 35.4 ± 14.7; female = 71.8%), individuals with a psychiatric diagnosis but no STB (i.e., clinical controls; n = 1871; mean age = 34 ± 14.8; female = 59.8%), and individuals with no psychiatric diagnosis and no STB (i.e., healthy controls; n = 642; mean age = 29.6 ± 13.1; female = 62.9%). We also compared these measures among individuals with recent suicidal ideation ( n = 714; mean age = 36.3 ± 15.3; female = 66.1%), clinical controls ( n = 1184; mean age = 36.8 ± 15.6; female = 63.1%), and healthy controls ( n = 1240; mean age = 31.6 ± 15.5; female = 61.0%). We found subtle but statistically significant effects, such as lower FA associated with a history of suicide attempt, over and above the effect of psychiatric diagnoses. These effects were strongest in the corona radiata, thalamic radiation, fornix/stria terminalis, corpus callosum and superior longitudinal fasciculus. Recent suicidal ideation was associated with higher AD in the cingulum. Effect sizes were small (partial eta-squared < 0.015). This large-scale coordinated mega-analysis revealed subtle regional and global alterations in WM microstructure in individuals with a history of suicide attempt and recent suicidal ideation. Longitudinal studies are needed to confirm whether these alterations are a risk factor for suicidal behaviour or ideation.

Previous studies have suggested that alterations in white matter (WM) microstructure are implicated in suicidal thoughts and behaviours (STBs). However, findings of diffusion tensor imaging (DTI) studies have been inconsistent. In this large-scale mega-analysis conducted by the ENIGMA Suicidal Thoughts and Behaviours (ENIGMA-STB) consortium, we examined WM alterations associated with STBs. Data processing was standardised across sites, and resulting WM microstructure measures (fractional anisotropy, axial diffusivity, mean diffusivity and radial diffusivity) for 25 WM tracts were pooled across 40 cohorts. We compared these measures among individuals with a psychiatric diagnosis and lifetime history of suicide attempt ( n =652; mean age=35.4±14.7; female=71.8%), individuals with a psychiatric diagnosis but no STB (i.e., clinical controls; n =1871; mean age=34±14.8; female=59.8%), and individuals with no mental disorder diagnosis and no STB (i.e., healthy controls; n =642; mean age=29.6±13.1; female=62.9%). We also compared these measures among individuals with recent suicidal ideation ( n =714; mean age=36.3±15.3; female=66.1%), clinical controls ( n =1184; mean age=36.8±15.6; female=63.1%), and healthy controls ( n =1240; mean age= 31.6±15.5; female=61.0%). We found subtle but statistically significant effects, such as lower fractional anisotropy associated with a history of suicide attempt, over and above the effect of psychiatric diagnoses. These effects were strongest in the corona radiata, thalamic radiation, fornix/stria terminalis, corpus callosum and superior longitudinal fasciculus. Effect sizes were small (Cohen’s d < 0.25). Recent suicidal ideation was not associated with alterations in WM microstructure. This large-scale coordinated mega-analysis revealed subtle regional and global alterations in WM microstructure in individuals with a history of suicide attempt. Longitudinal studies are needed to confirm whether these alterations are a risk factor for suicidal behaviour.

Background: Young people receiving tertiary mental health care are at elevated risk for suicidal behavior, and understanding which individuals are at increased risk during care is important for treatment and suicide prevention. Aim: We aimed to retrospectively identify risk factors for attempted suicide during outpatient care and predict which young people did or did not attempt during care. Method: Penalized logistic regression analysis was performed in a small high-risk sample of 84 young people receiving care at Orygen’s Youth Mood Clinic (age: 14–25 years, 51% female) to predict suicide attempt during care (N = 16). Results: Prediction of suicide attempt during care was only moderately accurate (Area Under the Receiver Operating Curve range 0.71; sensitivity 0.57) using a combination of sociodemographic, psychosocial, and clinical variables. The features that best discriminated both groups included suicidal ideation during care, history of suicide attempt prior to care, changes in appetite reported on the PHQ-9, history of parental separation, and parental mental illness. Limitation: Replication of findings in an independent validation sample is needed. Conclusion: While prediction of suicide attempt during care was only moderately successful, we were able to identify individual risk factors for suicidal behavior during care in a high-risk sample.

A major limitation of current suicide research is the lack of power to identify robust correlates of suicidal thoughts or behavior. Variation in suicide risk assessment instruments used across cohorts may represent a limitation to pooling data in international consortia. Here, we examine this issue through two approaches: (a) an extensive literature search on the reliability and concurrent validity of the most commonly used instruments and (b) by pooling data (N ∼ 6,000 participants) from cohorts from the Enhancing NeuroImaging Genetics Through Meta-Analysis (ENIGMA) Major Depressive Disorder and ENIGMA-Suicidal Thoughts and Behaviour working groups, to assess the concurrent validity of instruments currently used for assessing suicidal thoughts or behavior. We observed moderate-to-high correlations between measures, consistent with the wide range (κ range: 0.15-0.97; r range: 0.21-0.94) reported in the literature. Two common multi-item instruments, the Columbia Suicide Severity Rating Scale and the Beck Scale for Suicidal Ideation were highly correlated with each other (r = 0.83). Sensitivity analyses identified sources of heterogeneity such as the time frame of the instrument and whether it relies on self-report or a clinical interview. Finally, construct-specific analyses suggest that suicide ideation items from common psychiatric questionnaires are most concordant with the suicide ideation construct of multi-item instruments. Our findings suggest that multi-item instruments provide valuable information on different aspects of suicidal thoughts or behavior but share a modest core factor with single suicidal ideation items. Retrospective, multisite collaborations including distinct instruments should be feasible provided they harmonize across instruments or focus on specific constructs of suicidality. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: To reduce suicide in females with mood disorders, it is critical to understand brain substrates underlying their vulnerability to future suicidal ideation and behaviors (SIBs) in adolescence and young adulthood. In an international collaboration, grey and white matter structure was investigated in adolescent and young adult females with future suicidal behaviors (fSB) and ideation (fSI), and without SIBs (fnonSIB).Methods: Structural (n = 91) and diffusion‐weighted (n = 88) magnetic resonance imaging scans at baseline and SIB measures at follow‐up on average two years later (standard deviation, SD = 1 year) were assessed in 92 females [age(SD) = 16.1(2.6) years] with bipolar disorder (BD, 28.3%) or major depressive disorder (MDD, 71.7%). One‐way analyses of covariance comparing baseline regional grey matter cortical surface area, thickness, subcortical grey volumes, or white matter tensor‐based fractional anisotropy across fSB (n = 40, 43.5%), fSI (n = 33, 35.9%) and fnonSIB (n = 19, 20.6%) groups were followed by pairwise comparisons in significant regions (p < 0.05).Results: Compared to fnonSIBs, fSIs and fSBs showed significant decreases in cortical thickness of right inferior frontal gyrus pars orbitalis and middle temporal gyrus, fSIs of left inferior frontal gyrus, pars orbitalis. FSIs and fSBs showed lower fractional anisotropy in left uncinate fasciculus and corona radiata, and fSBs in right uncinate and superior fronto‐occipital fasciculi.Conclusions: The study provides preliminary evidence of grey and white matter alterations in brain regions subserving emotional and behavioral regulation and perceptual processing in adolescent and young adult females with mood disorders with, versus without, future SIBs. Findings suggest potential targets to prevent SIBs in female adolescents and young adults.

Identifying brain alterations associated with suicidal thoughts and behaviors (STBs) in young people is critical to understanding their development and improving early intervention and prevention. The ENIGMA Suicidal Thoughts and Behaviours (ENIGMA-STB) consortium analyzed neuroimaging data harmonized across sites to examine brain morphology associated with STBs in youth. We performed analyses in three separate stages, in samples ranging from most to least homogeneous in terms of suicide assessment instrument and mental disorder. First, in a sample of 577 young people with mood disorders, in which STBs were assessed with the Columbia Suicide Severity Rating Scale (C-SSRS). Second, in a sample of young people with mood disorders, in which STB were assessed using different instruments, MRI metrics were compared among healthy controls without STBs (HC; N = 519), clinical controls with a mood disorder but without STBs (CC; N = 246) and young people with current suicidal ideation (N = 223). In separate analyses, MRI metrics were compared among HCs (N = 253), CCs (N = 217), and suicide attempters (N = 64). Third, in a larger transdiagnostic sample with various assessment instruments (HC = 606; CC = 419; Ideation = 289; HC = 253; CC = 432; Attempt=91). In the homogeneous C-SSRS sample, surface area of the frontal pole was lower in young people with mood disorders and a history of actual suicide attempts (N = 163) than those without a lifetime suicide attempt (N = 323; FDR-p = 0.035, Cohen’s d = 0.34). No associations with suicidal ideation were found. When examining more heterogeneous samples, we did not observe significant associations. Lower frontal pole surface area may represent a vulnerability for a (non-interrupted and non-aborted) suicide attempt; however, more research is needed to understand the nature of its relationship to suicide risk.