The risk of suicide is substantially elevated among people with psychotic disorders, and the presence of psychosis is associated with more severe attempts and a higher likelihood of progression from suicidal ideation to suicide attempt. The risk factors associated with suicide in psychotic disorders are somewhat divergent from those in the broader population, including that greater cognitive ability is associated with higher probability of suicidal behavior. Unfortunately, the great majority of recent suicide prevention trials exclude psychosis. Despite the prominence of cognitive dysfunction in psychotic disorders, little research has systematically evaluated potential neurocognitive mechanisms contributing to suicidal ideation and behavior in psychotic disorders. Preliminary data from our research group and others indicates that social cognitive biases, such as misperceptions of threat in others and valuation of relationships, may be particularly relevant to suicidality in psychosis. Social cognitive biases may also be influenced by context, and our research with ecological momentary assessment (EMA) evidences that negative biases toward others may be exacerbated when people with psychosis are alone. These biases represent potential treatment targets that, once validated, could set the stage for novel suicide prevention interventions in psychotic disorders. To address these gaps in the literature, we propose a four-year three-site (UCSD, University of Miami, University of Texas at Dallas) longitudinal observational research study in which outpatients with psychotic disorders (e.g., schizophrenia, bipolar disorder with psychosis), stratified by presence of suicidal ideation at baseline, will be followed for one year and repeatedly assessed for social cognitive biases, suicidal ideation and behavior, and other pertinent risk factors. Innovation includes use of a measurement burst design, which integrates repeated lab-based measures with concurrent EMA of real-time social appraisals, behavior, and contexts; this burst design enables simultaneously evaluation of constructs over day-to-day and longer-term time scales. The proposed research builds upon prior collaboration between the investigators in the areas of psychotic disorders, measurement, social cognition, ecological momentary assessment, and more recently suicide research.
Our Aims evaluate the association between social cognitive biases and suicidal ideation and behavior at baseline, predictive accuracy of these biases in trajectories of ideation and interim suicidal behavior, and within-person change in dynamic associations between biases, social appraisals, and contexts integrating data from in-lab and EMA modalities. This proposal responds directly to the recent Prioritized Research Agenda for Suicide Prevention, which identified a short-term goal to identify cognitive dysfunction profiles that may amenable to current interventions, NIMH Strategic Aim 3.1 to identify and validate new targets for intervention that underlie disease mechanisms, and the NIMH Digital Health priority area.

Public Health Relevance

Psychotic disorders, such as schizophrenia, are associated with a high risk for suicide, and yet little scientific research has been conducted on the potential treatment targets for suicide prevention for this group. This naturalistic project focuses on the link, over time, between cognitive biases in how patients perceive other people and suicidal thinking and behavior in psychotic disorders. These biases will be simultaneously measured with laboratory tests and with repeated mobile technology, with an overarching goal of this research to inform novel suicide prevention interventions for people with psychotic disorders.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Adult Psychopathology and Disorders of Aging Study Section (APDA)
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Leitman, David I
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University of California, San Diego
Schools of Medicine
La Jolla
United States
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