The role of emotion regulation in predicting suicide risk in depressed individuals

Depressed people who reflexively try to suppress their initial emotional responses to reminders of negative memories generally have a low tolerance for distressing emotional stimuli and may respond to stress in everyday life by increasing suicidal thoughts. New research in Biological psychiatry: cognitive neuroscience and neuroimagingpublished by Elsevier, examined the association of emotion regulation engagement with real-world stress responses to better understand the stress-related increase in suicide risk in depression.

Suicide rates in the United States have increased by approximately 37% since 2000. To reverse this trend, we must understand how suicide risk appears in everyday life, and in particular the biopsychosocial factors that can influence the ebbs and flows of suicide risk.

J. John Mann, MD, Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute

Retrospective reports show that the most immediate cause of suicidal acts is a stressful life event, but researchers say it is very difficult to prospectively examine how stress influences the occurrence of acute suicidality.

Co-first author Sarah Herzog, PhD student, Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute; and Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, explains: “Ecological momentary assessment allows us to observe how people suffering from depression respond to stressful events in everyday life, such as increased suicidal thoughts and worsening mood. Our study went a step further by linking a laboratory biological risk marker in a depression sample to naturalistic responses to everyday, real-world stressors. This multimodal method may improve the prediction of suicide risk in suicide-prone individuals and possibly aid in effective intervention for potentially life-threatening stress reactions.

A group of 82 participants suffering from major depressive disorder was studied using two innovative methods. First, an MRI (fMRI)-based functional neural signature for cognitive reappraisal – an emotion regulation strategy – quantified the degree to which individuals engaged in emotion regulation when recalling personal negative memories. The researchers then used ecological momentary assessment (EMA), which involves prospective, repeated measurement of participants’ thoughts and emotions in a naturalistic setting. EMA provides insight into how individuals respond to stressors in everyday life, manifesting as changes in mood symptoms and suicidal thoughts. The researchers then used the fMRI-based neural signature of emotion regulation expressed during an autobiographical memory task to predict participants’ responses to everyday life stressors during EMA.

The study found that depressed people who spontaneously engaged a neural signature of emotion regulation when personal negative memories emerged also experienced greater increases in suicidal thoughts during daily stressful events over the course of a week. When participants were instructed to use reappraisal, they showed more adaptive responses to stress.

Editor-in-Chief Biological psychiatry: cognitive neuroscience and neuroimaging Cameron S. Carter, MD, University of California, Irvine, comments: “Fflexibility in emotion regulation is generally understood as a determinant of mental health. However, in the current study, researchers found that reflexively engaging in emotion regulation when faced with unexpected stressors may not be helpful or effective in all circumstances. These findings, using functional imaging combined with assessments of real-world situations, are important for better understanding how to effectively cope with stress in everyday life.”

Co-first author Noam Schneck, PhD, Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute; and Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, notes: “The use of neural decoding allows us to identify mental processes that were previously elusive to grasp, such as spontaneous emotion regulation. In future work, the decoder approach may be used to better understand how emotion regulation is engaged spontaneously to modulate hour-to-hour daily experience, thereby influencing suicide risk in variable ways.

Senior author of the current study Barbara H. Stanley, MD, Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute; and Department of Psychiatry and Clinic RadiologyColumbia University Vagelos College of Physicians and Surgeons, who died in 2023, played a key role in designing this study. Recognizing her valuable contribution to this work, Dr. Mann notes: “It was Dr. Stanley’s idea that we use ecological momentary assessment in the same depressed patients who had performed the fMRI study on negative autobiographical memories. It was this combination of research procedures that led to these extraordinary discoveries.”