Neural correlates of suicidal behaviour: a longitudinal study

Suicide is an urgent societal problem, with alarming numbers that steadily
increase in the Netherlands. However, the exact social, psychological and brain
mechanisms underlying the risk of suicidal behavior remain largely unknown. It
has been proposed that suicidal ideation may result from altered
social-emotional processing, e.g. difficulties in cognitive control of emotion,
in the face of adversity. This would lead to a *psychological pain* that can
fuel hopelessness. Another important ingredient of hopelessness is a lack of
flexibility to envision positive future scenarios. Feeling trapped in this
desperate situation, suicide can be seen as the only solution. To come to the
suicidal act some facilitating factors come into play, which we hypothesize to
include reduced ability to take the perspective of others (which may reduce
empathy in weighing the emotional consequences for close others). However, the
exact nature of this process has not yet been elucidated. In this study, we
will for the first time, examine several key cognitive-emotional processes in
relation to suicidal behavior using brain imaging: emotion regulation,
envisioning future positive events and inferring on emotions of others. In
addition, neural markers may identify those patients at high risk of future
suicidality (suicide attempts and/or ideation) and can contribute to the
development of more personalized treatment options by shedding light on the
processes involved. Moreover, it is not yet known whether and to which extent
such (neural) mechanisms "normalize" with time and treatment (i.e. are more
similar to healthy comparison subjects). Most of the time participants receive
a treatment with elements of cognitive behavior therapy (CBT) to reduce
suicidal thoughts and behavior.

The objectives of this study are threefold. First, we aim to understand the
underlying neural mechanisms of suicidality. Therefore, we will investigate
brain activation during resting state and three psychological processes that
have been suggested to be of relevance to suicidality, but have not been
studied yet using brain imaging: emotion regulation, positive imagery of future
change and inferring on emotions of others. Second, to identify who is at risk
for relapse of suicidal behavior despite adequate application of standard
treatment protocol, we will investigate whether brain activation could serve as
a marker for future suicidality, including both suicidal ideations and
attempts. Third, to understand and target the underlying mechanisms, it is
essential to know which mechanisms can be altered and are influenced by the
current state of suicidality.

The current study has an experimental design. We will employ a longitudinal
fMRI study in which we will follow a group of recent suicide attempters, for
one year and patients with comparable psychopathology for six months. The tasks
during fMRI scanning intend to measure emotion regulation, affective
forecasting and inferring emotions of others. Furthermore, several interviews
and questionnaires will be administered.

First, participants are asked to fill in questionnaires and interviews are
held. For the patients with suicidal behavior, this will be divided over two
days, for the control groups only one appointment will be scheduled. Second,
participants will undergo (f)MRI scanning, during which participants have to
perform tasks related to emotion regulation, envisioning positive future events
and inferring on emotions of others, in addition a resting state scan and an
anatomy scan will be made. This (f)MRI session will take approximately 75
minutes. After one year, for the patients with suicidal behavior, this whole
session will be repeated. In between, participants will receive treatment in
accordance with current guidelines. All participants will be asked to fill in
the suicidal ideation questionnaire after one, three and six months. This will
take approximately 10 minutes. This will be done via mail.
Concerning the fMRI scanner, participants will be exposed to a field strength
of 3 Tesla and to the noise of the scanner. Thus far, there is no evidence to
suggest that exposing humans to a magnetic field of this strength has a
negative influence on health. With regard to the noise, earplugs will be
provided.
The suicide-attempted patients are a vulnerable group of people. Therefore, we
will pro-actively offer a safety network for the suicide-attempted patients.
This could benefit the patient that he/she will be actively be kept an eye on
for the period of a year. This might help in prevention of a new attempt. We
will do this by asking the participants to name a few people as their safety
network, which we can contact in case we have suspicions about the well-being
of the person or assess presence of suicidal ideation based on the follow-up
measurements. This network will include the main psychiatric caregiver and
family doctor.
The study is not intended to benefit the participants directly. However, the
data collected during this study will enhance understanding of the neural basis
of suicidal behavior. Participants receive a compensation of ¤30 for each MRI
session( patients with suicidial behavior will receive ¤60 after completion of
the baseline and follow-up measurement) for their participations.