Jeremy G. Stewart

Identifying differences between depressed adolescent suicide ideators and attempters

BACKGROUND Adolescent depression and suicide are pressing public health concerns, and identifying key differences among suicide ideators and attempters is critical. The goal of the current study is to test whether depressed adolescent suicide attempters report greater anhedonia severity and exhibit aberrant effort-cost computations in the face of uncertainty. METHODS Depressed adolescents (n=101) ages 13-19 years were administered structured clinical interviews to assess current mental health disorders and a history of suicidality (suicide ideators=55, suicide attempters=46). Then, participants completed self-report instruments assessing symptoms of suicidal ideation, depression, anhedonia, and anxiety as well as a computerized effort-cost computation task. RESULTS Compared with depressed adolescent suicide ideators, attempters report greater anhedonia severity, even after concurrently controlling for symptoms of suicidal ideation, depression, and anxiety. Additionally, when completing the effort-cost computation task, suicide attempters are less likely to pursue the difficult, high value option when outcomes are uncertain. Follow-up, trial-level analyses of effort-cost computations suggest that receipt of reward does not influence future decision-making among suicide attempters, however, suicide ideators exhibit a win-stay approach when receiving rewards on previous trials. LIMITATIONS Findings should be considered in light of limitations including a modest sample size, which limits generalizability, and the cross-sectional design. CONCLUSIONS Depressed adolescent suicide attempters are characterized by greater anhedonia severity, which may impair the ability to integrate previous rewarding experiences to inform future decisions. Taken together, this may generate a feeling of powerlessness that contributes to increased suicidality and a needless loss of life.

Psychological interventions to reduce suicidality in high-risk patients with major depression: a randomized controlled trial.

BACKGROUND Positive psychological constructs have been associated with reduced suicidal ideation, and interventions to cultivate positive feelings have the potential to reduce suicide risk. This study compares the efficacy of a 6-week, telephone-based positive psychology (PP) intervention against a cognition-focused (CF) control intervention among patients recently hospitalized for depression and suicidal ideation or behavior. METHOD A total of 65 adults with a current major depressive episode reporting suicidal ideation or a recent suicide attempt were enrolled from participating in-patient psychiatric units. Prior to discharge, participants were randomized to the PP (n = 32) or CF (n = 33) intervention. In both interventions, participants received a treatment manual, performed weekly PP (e.g. gratitude letter) or CF (e.g. recalling daily events) exercises, and completed weekly one-on-one telephone sessions over 6 weeks. Between-group differences in hopelessness (primary outcome), depression, suicidality and positive psychological constructs at 6 and 12 weeks were tested using mixed-effects models accounting for intensity of post-hospitalization psychiatric treatment. RESULTS Compared with PP, the CF intervention was associated with significantly greater improvements in hopelessness at 6 weeks (β = -3.15, 95% confidence interval -6.18 to -0.12, effect size = -0.84, p = 0.04), but not 12 weeks. Similarly, the CF intervention led to greater improvements in depression, suicidal ideation, optimism and gratitude at 6 and 12 weeks. CONCLUSIONS Contrary to our hypothesis, the CF intervention was superior to PP in improving hopelessness, other suicide risk factors and positive psychological constructs during a key post-discharge period among suicidal patients with depression. Further study of this CF intervention is warranted in populations at high suicide risk.

Childhood emotional and sexual maltreatment moderate the relation of the serotonin transporter gene to stress generation.

Emerging evidence suggests that the tendency to generate stressful life events may be, at least in part, genetically determined. However, the role of the early environment in shaping responses to later stressors is crucial to fully specifying biogenetic models of stress generation. The current study examined the moderating role of childhood emotional, physical, and sexual maltreatment on the relation of the serotonin-transporter-linked promoter region (5-HTTLPR) polymorphism of the serotonin transporter gene to proximal independent, dependent, and dependent-interpersonal life events. This question was tested in a cross-sectional community sample of 297 adolescents and young adults. Childhood maltreatment history and proximal life events were assessed with state-of-the-art interviews that provide independent and standardized ratings of the environmental context. Consistent with the stress generation hypothesis, individuals with the risk s-allele of the serotonin transporter gene reported significantly higher rates of dependent and dependent-interpersonal life events than those homozygous for the l-allele, but only in the context of a history of maternal emotional maltreatment or sexual maltreatment. Neither serotonin transporter gene polymorphisms or childhood maltreatment, or their interaction, were associated with reports of independent life events. The current results demonstrate the importance of considering specificity in the early environmental context when examining the relation of genetic factors to the generation of proximal stress.

Borderline personality disorder in youth: The prospective impact of child abuse on non-suicidal self-injury and suicidality

BACKGROUND Borderline personality disorder (BPD) is characterized by greater engagement in non-suicidal self-injury (NSSI) and suicidality. The aim of the study is to test whether the occurrence of child abuse contributes to these high-risk behaviors in BPD youth. MATERIALS AND METHODS BPD female youth aged 13-21years with (n=29) and without (n=29) a history of child abuse were administered clinical interviews assessing diagnostic history, child abuse, NSSI and suicidality (i.e., ideation, plans, and attempts). NSSI and suicidality were subsequently reevaluated at the 1- and 2-month follow-up assessments. RESULTS Several findings emerged. First, relative to BPD youth without abuse, the abuse group reported greater past NSSI; however, no significant differences emerged in the follow-up period. Second, the occurrence of child abuse was associated with a 5-fold increase in the rate of lifetime suicide attempts relative to the no abuse group and additionally, prospectively predicted suicide ideation (but not attempts). Last, exploratory analyses indicated that the co-occurrence of physical and sexual abuse was associated with greater past NSSI and suicidality as compared to the no abuse and sexual abuse only participants. CONCLUSION As a whole, child abuse - particularly co-occurring physical and sexual abuse - increases risk for NSSI and suicidality among BPD youth, which may have important treatment implications in this high-risk population.

Electrocortical Reactivity During Self-referential Processing in Female Youth With Borderline Personality Disorder

BACKGROUND Borderline personality disorder (BPD) is debilitating, and theoretical models have postulated that cognitive-affective biases contribute to the onset and maintenance of BPD symptoms. Despite advances, our understanding of BPD pathophysiology in youth is limited. The present study used event-related potentials (ERPs) to identify cognitive-affective processes that underlie negative self-referential processing in BPD youth. METHODS Healthy females (n = 33) and females with BPD (n = 26) 13 to 22 years of age completed a self-referential encoding task while 128-channel electroencephalography data were recorded to examine early (i.e., P1 and P2) and late (late positive potential [LPP]) ERP components. Whole-brain standardized low-resolution electromagnetic tomography explored intracortical sources underlying significant scalp ERP effects. RESULTS Compared to healthy females, participants with BPD endorsed, recalled, and recognized fewer positive and more negative words. Moreover, unlike the healthy group, females with BPD had faster reaction times to endorse negative versus positive words. In the scalp ERP analyses, the BPD group had greater P2 and late LPP positivity to negative as opposed to positive words. For P2 and late LPP, whole-brain standardized low-resolution electromagnetic tomography analyses suggested that females with BPD overrecruit frontolimbic circuitry in response to negative stimuli. CONCLUSIONS Collectively, these findings show that females with BPD process negative self-relevant information differently than healthy females. Clinical implications and future directions are discussed.

EMOTION-PROCESSING BIASES AND RESTING EEG ACTIVITY IN DEPRESSED ADOLESCENTS

Although theorists have posited that adolescent depression is characterized by emotion‐processing biases (greater propensity to identify sad than happy facial expressions), findings have been mixed. Additionally, the neural correlates associated with putative emotion‐processing biases remain largely unknown. Our aim was to identify emotion‐processing biases in depressed adolescents and examine neural abnormalities related to these biases using high‐density resting EEG and source localization.

Emotion processing in female youth: Testing the stability of the late positive potential

The Emotional Interrupt Task (EIT) has been used to probe emotion processing in healthy and clinical samples; however, research exploring the stability and reliability of behavioral measures and ERPs elicited from this task is limited. Establishing the psychometric properties of the EIT is critical, particularly as phenotypes and biological indicators may represent traitlike characteristics that underlie psychiatric illness. To address this gap, test-retest stability and internal consistency of behavioral indices and ERPs resulting from the EIT in healthy, female youth (n = 28) were examined. At baseline, participants were administered the EIT while high-density 128-channel EEG data were recorded to probe the late positive potential (LPP). One month later, participants were readministered the EIT. Four principal findings emerged. First, there is evidence of an interference effect at baseline, as participants showed a slower reaction time for unpleasant and pleasant images relative to neutral images, and test-retest of behavioral measures was relatively stable over time. Second, participants showed a potentiated LPP to unpleasant and pleasant images compared to neutral images, and these effects were stable over time. Moreover, in a test of the difference waves (unpleasant-neutral vs. pleasant-neutral), there was sustained positivity for unpleasant images. Third, behavioral measures and LPP demonstrated excellent internal consistency (odd/even correlations) across conditions. Fourth, highlighting important age-related differences in LPP activity, younger age was associated with larger LPP amplitudes across conditions. Overall, these findings suggest that the LPP following emotional images is a stable and reliable marker of emotion processing in healthy youth.

Neuroanatomical Prediction of Anhedonia in Adolescents

Anhedonia is a transdiagnostic risk factor implicated in mental illness onset, treatment non-response, and suicidal behaviors. Prior cross-sectional research in adults has shown that anhedonia is associated with reduced dorsal striatal volume, but it is unknown whether this relationship extends to adolescents and whether reduced striatal volume prospectively predicts anhedonia. To address these gaps, the current study investigated whether striatal volume predicted anhedonia severity in adolescents. At baseline, healthy female adolescents aged 12–14 years (n=50) completed a clinical assessment, and structural MRI data were acquired on a 3 Tesla MR scanner. While in the scanner, participants also completed a peer feedback task where subjective ratings following peer ‘acceptance’ or ‘rejection’ were obtained. At the three-month follow-up, participants provided self-report assessments of anhedonia, depression, and anxiety symptoms. Three main findings emerged. First, in cross-sectional analyses, right nucleus accumbens volume was inversely related to anhedonia severity. Second, reduced bilateral putamen volume prospectively predicted anhedonia severity while controlling for baseline anhedonia, depression, and anxiety symptoms. Third, a blunted subjective response to peer acceptance (ie, neutral response to positive feedback), but not a more negative subjective response to peer rejection, contributed to anhedonia severity, but only among youth with smaller putamen volume. Collectively, these results suggest that smaller volume in striatal regions critically implicated in reward processing is associated with current and future anhedonic symptoms among healthy female youth. These anatomical features may confer vulnerability to anhedonia and thus, may inform early identification of individuals at high risk for mental illness.

Cognitive Control Deficits Differentiate Adolescent Suicide Ideators From Attempters

OBJECTIVE Mental illness and suicidal ideation are among the strongest correlates of suicidal behaviors, but few adolescents with these risk factors make a suicide attempt. Therefore, it is critical to identify factors associated with the transition from suicide ideation to attempts. The present study tested whether deficits in cognitive control in the context of suicide-relevant stimuli (ie, suicide interference) reliably differentiated adolescent ideators and attempters. METHODS Adolescents (n = 99; 71 girls) aged 13-18 years (mean = 15.53, SD = 1.34) with recent suicide ideation (n = 60) or a recent suicide attempt (n = 39) were recruited from an acute residential treatment facility between August 2012 and December 2013. We measured interference to suicide-related, negative, and positive words using the Suicide Stroop Task (SST). RESULTS When stimuli were analyzed separately, suicide attempters showed greater interference for suicide (t₉₇ = 2.04, P = .044, d = 0.41) and positive (t₉₇ = 2.63, P = .010, d = 0.53) stimuli compared to suicide ideators. An additional omnibus interference (suicide, negative, positive) x group (suicide ideator, suicide attempter) analysis of variance revealed a main effect of group (F₁,₉₇ = 4.31, P = .041, ηp² = 0.04) but no interaction (P = .166), indicating that attempters showed greater interference for emotional stimuli, regardless of valence. Multiple attempters drove this effect; single attempters and ideators did not differ in SST performance (P = .608). CONCLUSIONS General deficits in cognitive control in the context of emotional stimuli may be a marker of adolescent suicide risk.

A longitudinal investigation of the Concise Health Risk Tracking Self-Report (CHRT-SR) in suicidal patients during and after hospitalization

The Concise Health Risk Tracking Self-Report (CHRT-SR) scale is a brief self-report instrument to assess suicide risk. Initial investigations have indicated good psychometric properties in psychiatric outpatients. The aims of this paper were to examine the construct validity and factor structure of the twelve- (CHRT-SR12) and seven-item (CHRT-SR7) versions and to test if clinically expected within-person changes in suicide risk over time were measurable using the CHRT-SR in two study cohorts hospitalized for suicidal ideation or behavior: (1) patients with major depressive disorder (MDD) who participated in a psychological intervention trial, n = 65, and (2) participants with bipolar disorder or MDD in an observational study, n = 44. The CHRT-SR12 and self-report measures of hopelessness, depression, and positive psychological states were administered during admission and several times post-discharge. Both versions showed good internal consistency in inpatients and confirmed the three-factor structure (i.e., hopelessness, perceived lack of social support and active suicidal ideation and plans) found in outpatients. CHRT-SR scores had strong correlations with negative and positive affective constructs in the expected directions, and indicated decreases in suicide risk following discharge, in line with clinical expectations. The CHRT-SR12 and CHRT-SR7 are promising self-report measures for assessing suicide risk in very high-risk patient populations.