Research paper
Are suicidal thoughts reinforcing? A preliminary real-time monitoring study on the potential affect regulation function of suicidal thinking

https://doi.org/10.1016/j.jad.2018.02.033Get rights and content

Highlights

  • Some patients may experience relief from negative mood after suicidal thoughts.

  • Suicidal thoughts were followed by downward shifts in negative mood.

  • This provides the first evidence that suicidal thinking leads to shifts in mood.

  • These shifts may be reinforcing, making suicidal thinking persistent.

Abstract

Background

Theoretical work and clinical observation suggest that many patients experience relief from negative affect after thinking about suicide, which may increase the likelihood of future suicidal thoughts. Accordingly, our objective was to examine whether the occurrence of suicidal thinking was followed by decreased negative affect and increased positive affect.

Methods

Participants were 43 adults who attempted suicide at least once in the past year (78% female, 78% White, M age = 23.28 years, SD age = 4.38 years) who completed 28 days of smartphone-based real-time monitoring, where they were signaled four times/day to report on current affect and whether they were having suicidal thoughts. Participants could initiate a survey whenever they had a suicidal thought.

Results

First, we examined changes in affect that occurred when suicidal thinking at the current time (T) but not at T + 1 (approximately 4–8 h later). Negative affect decreased and positive affect increased when participants went from a period when they were experiencing suicidal thoughts to a period where they were not. Second, to assess the time course of changes in affect, we examined changes in affect before and after participant-initiated reports of suicidal thinking. Positive affect increased and sadness decreased.

Limitations

Given its preliminary nature, the study has some limitations including insufficient power to expand beyond a 4–8 h timespan.

Conclusions

Findings provide preliminary evidence that suicidal thinking leads to shifts in affect. These shifts in affect may be reinforcing, helping to explain (in part) why suicidal thinking is so persistent for some patients.

Introduction

Theoretical work and clinical observation suggest that many patients experience relief after thinking about suicide, which they perceive as comforting or as providing an escape from their seemingly intolerable circumstances (Gordon et al., 2010, O’Connor, 2003, Selby et al., 2007). This might mean that recurrent suicidal thinking is maintained because it leads to downward shifts in negative affect (i.e., negative reinforcement by providing an escape) or upward shifts in positive affect (i.e., positive reinforcement by providing comfort). Two prior studies that asked people who had suicidal thoughts in the past to recall how they felt when having suicidal thoughts reported that people recall feeling distressed when thinking about suicide, but some people also report comfort in the context of suicidal thinking (Crane et al., 2014, Crane et al., 2012). These earlier findings are intriguing, but are limited by a reliance on long-term retrospective recall and a failure to repeatedly assess changes in affective states from before to after the occurrence of suicidal thinking.

Smartphone-based ecological momentary assessment (EMA) approaches now allow for the collection of data about changes in affective states as they occur throughout the day (Kleiman and Nock, 2018, Shiffman et al., 2008). EMA studies on non-suicidal self-injury (NSSI) have shown, for instance, that engagement in NSSI is associated with decreases in negative affective and increases in positive affect, which seem to reinforce this behavior (Ammerman et al., 2017, Nock et al., 2009). No prior studies have examined whether thinking about suicide may be associated with similar affective changes. Here we used real-time, smartphone-based assessments to capture shifts in affect in situ. We expected to find that episodes of suicidal thinking are associated with subsequent decreases in negative affect and increases in positive affect.

Section snippets

Participants/recruitment

Inclusion criteria for this Harvard University IRB-approved study were: (1) a suicide attempt in the past year, (2) age 18 +, (3) ability to read English fluently, and (4) access to a compatible Android or iPhone smartphone. We recruited from a variety of suicide-related online message boards on Reddit (www.reddit.com). A total of 854 people completed the screener for the study, 103 of whom qualified (744 out of the 751 who did not qualify for the study had not attempted suicide in the past

Preliminary analyses

The sample was 78% female, 73% White, and had a mean age of 23.28 years (SD age = 4.38 years). There were 305 pairs of responses occurring during the same day where participants reported suicidal thinking at T but not at T + 1 (M = 7.09 pairs of responses per participant, SD = 5.23, range 1–20), out of a total of 540 pairs of responses. The average time between these pairs of responses was 7.95 h (SD = 5.35). There were 37 participant-initiated reports of suicidal thinking by 14 participants (M

Discussion

The goal of this study was to explore where the occurrence of suicidal ideation lead to downward shifts in negative affect and upward shifts in positive affect. There were two main findings that provide preliminary evidence for this hypothesis. First, we found decreases in negative affect (and its component parts) and increases in positive affect (and its component parts) when participants went from a period when they were experiencing suicidal thoughts to a period where they were no longer

Acknowledgements

Funding provided by Pershing Square Venture Fund for Research on the Foundations of Human Behavior (EMK) and the John T. and Catherine D. MacArthur Foundation (MKN).

References (18)

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