Lethal Forethought: Delayed Reward Discounting Differentiates High- and Low-Lethality Suicide Attempts in Old Age

Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania 15213, USA.
Biological psychiatry (Impact Factor: 10.26). 02/2011; 70(2):138-44. DOI: 10.1016/j.biopsych.2010.12.025
Source: PubMed


The decision to commit suicide may be impulsive, but lethal suicidal acts often involve planning and forethought. People who attempt suicide make disadvantageous decisions in other contexts, but nothing is known about the way they decide about the future. Can the willingness to postpone future gratification differentiate between individuals prone to serious, premeditated and less serious, unplanned suicidal acts?
Four groups of depressed participants aged 60 and older made choices between smaller immediate and larger delayed monetary rewards: 15 who had made high-lethality suicide attempts, 14 who had made low-lethality suicide attempts, 12 who seriously contemplated suicide, and 42 people with depression, but no history of suicidal thoughts. The reference group was 31 psychiatrically healthy elders.
Individuals who had made low-lethality attempts displayed an exaggerated preference for immediate rewards compared with nonsuicidal depressed and healthy control subjects. Those who had carried out high-lethality suicide attempts were more willing to delay future rewards, compared with low-lethality attempters. Better planned suicide attempts were also associated with willingness to wait for larger rewards. These effects were unchanged after accounting for education, global cognitive function, substance use disorders, psychotropic medications, and possible brain injury from attempts. Discount rates were correlated with having debt, but were not significantly associated with income, hopelessness, depressive severity, premorbid IQ, age at first attempt, or choice of violent means.
Although clinicians often focus on impulsivity in patients at risk for suicide, these data suggest that identifying biological characteristics and treatments for nonimpulsive suicidal older people may be even more important.

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    • "We found in two partially overlapping samples that both suicide attempters and suicide ideators exhibited greater executive impairment than did non-suicidal individuals with depression (Dombrovski et al., 2008; Gujral et al., 2013). However, several other studies from our group have shown selective impairments in cognitive and decision processes among suicide attempters, relative to ideators, and non-suicidal depressed older adults (Dombrovski et al., 2010; Clark et al., 2011; Dombrovski et al., 2011). "
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    • "Although consistent with a model in which the ability to pursue death despite discomfort is of great importance in suicidal behavior, the distress tolerance findings assess a construct that is only tangentially related to persistence . Among older adults with prior suicidal behavior , individuals with more lethal attempts persisted longer in a delay discounting task, indicating that they are more willing to persist for a greater duration to obtain a larger reward (Dombrovski et al., 2011). Although such work highlights the importance of persistence , further work considering variables specifically focused on persistence towards goals would be highly useful and two variables in particular seem to have potential worth in this regard: grit and perseverance. "
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    • "Moreover, studies examining the level of planning involved in specific attempts have demonstrated a consistent (albeit not universal) inverse association between attempt impulsivity and attempt lethality (e.g., Baca-Garcia et al., 2001; Connor et al., 2006; Witte et al., 2008; Nakagawa et al., 2009; see Brown et al., 1991 for conflicting results). For example, in a sample of 83 older adult inpatients, Dombrovski et al. (2011) found that individuals with a history of suicide attempts who were better able to delay reward reported greater attempt lethality. Likewise, in a sample of 273 inpatient attempters, Monnin et al. (2012) found that violent suicide attempts were associated with less cognitive impulsivity than were nonviolent attempts. "
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