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Original Article
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Medical Journal of the Islamic Republic of Iran (MJIRI)
Med J Islam Repub Iran. 2024 (4 Nov);38.127. https://doi.org/10.47176/mjiri.38.127
Clinical and Neuropsychological Features of Suicide Attempters in
Tehran, Iran: A Comparative Study
Mozhgan Taban1, Vahid Sadeghi-Firoozabadi2, Seyed Kazem Malakouti3, Negar Bastani4, Marzieh Nojomi5, Ehsan
Rajabi6, Nafee Rasouli7*
Received: 24 Feb 2024 Published: 4 Nov 2024
Abstract
Background: Identifying suicide risk factors and understanding the variations among different clinical groups can play a crucial role
in preventing suicide. The objective of this study is to examine the distinctions in clinical and neuropsychological features among suicidal
attempters, who have attempted in the last four weeks.
Methods: The design of the study was a case–control study. This study consisted of 62 participants who were assigned to the suicide
attempters group (SA+MDD), non-suicidal depressed group (MDD), and healthy control group (HC). Clinical and neuropsychological
evaluations were conducted for all participants. The Kolmogorov-Smirnov test was used to evaluate the normality of distribution. To
compare the quantitative variables among the three groups, we employed Analysis of Variance (ANOVA), and Kruskal-Wallis. Post hoc
analysis was conducted using Dunnett's test. A correlation analysis was conducted between clinical and neuropsychological variables.
Results: The results showed that there was no significant difference in neuropsychological functions among the three groups except
Scaled Score Similarities (P=0.007). However, there were significant mean differences observed across the SA+MDD and HC groups
for BHS (P<0.001), SSI (P<0.001), RFL (P<0.001), BPAQ (P=0.037), Anxiety-springer-1 (P<0.001), Anxiety-springer-2 (P<0.001),
and BDI (P<0.001). Specifically, this difference was significant just for SSI (P<0.001), and RFL (P<0.001) when comparing the
SA+MDD and MDD groups. Some significant correlations were seen between clinical and neuropsychological features among suicide
attempters. Among neuropsychological features, Motor screening with BIS (P<0.001), Gambling test with SIS (P=0.04), Digit span with
BPAQ (P=0.04), anxiety-springer-1 (P=0.07), and BDI (P=0.005), arithmetic task with SIS (P=0.004), BPAQ (P=0.004), anxiety-
springer-1 (P=0.03), and anxiety-springer-2 (P=0.008), block design task with SIS (P=0.002), and BPAQ (P=0.03), Rapid Visual
Information with BIS (P=0.01), anxiety-springer-2 (P=0.04), and BDI (P=0.003), digital symbol task with BIS (P=0.02), and BDI
(P=0.008), and the Picture Completion task with BHS (P= 0.04), had more negative/positive correlation with clinical features.
Conclusion: Some clinical features such as hopelessness should be deemed serious among individuals with suicide attempt particularly
among those who were discharged recently. neuropsychological findings revealed functional disturbances in the frontal, parietal and
temporal areas of the subjects who are at risk of suicide attempt. The findings can inform the design and implementation of suicide
prevention programs. Targeted interventions can be developed to address the identified risk factors and protective factors associated with
suicide, such as increasing reasons for living, improving social connectedness, and building resilience.
Keywords: Suicide, Neuropsychology, Clinical Feature, Major Depressive Disorder
Conflicts of Interest: None declared
Funding: This study was financially supported by the National Institute of Medical Sciences Research Development (NIMAD), with grant number 973600.
*This work has been published under CC BY-NC-SA 4.0 license.
Copyright© Iran University of Medical Sciences
Cite this article as: Taban M, Sadeghi-Firoozabadi V, Malakouti SK, Bastani N, Nojomi M, Rajabi E, Rasouli N. Clinical and Neuropsychological
______________________________
Corresponding author: Dr Nafee Rasouli,
Rasouli.n@iums.ac.ir
1.
Mental Health Research Center, Psychosocial Health Research Institute, Iran
University of Medical Sciences, Tehran, Iran
2.
School of Psychology, Shahid Beheshti University, Tehran, Iran
3.
Geriatric Mental Health Research Center, School of Behavioral Sciences and Mental
Health, Iran University of Medical Sciences, Tehran, Iran
4.
Department of Education and Training, Tavistock and Portman N HS Foundation
Trust,Tavistock Centre, London, UK
5.
Preventive Medicine and Public Health Research Center, Psychosocial Health
Research Institute, Department of Community and Family Medicine, Iran University
of Medical Sciences, Tehran, Iran
6.
Department of Psychology, Shahid Beheshti University of Medical Sciences, Tehran,
Iran
7.
Department of Clinical Psychology, School of Behavioral Sciences and Mental Heal th,
Iran, University of Medical Sciences, Tehran, Iran
↑What is “already known” in this topic:
MDD patients with a history of suicide attempts exhibit significant
differences in cognitive and clinical characteristics compared to
MDD patients without suicide attempts and to healthy individuals.
→What this article adds:
Further research is needed to better understand cognitive function in
suicidal individuals and how it differs from other groups. However,
clinical characteristics serve as a significant factor in distinguishing
suicidal individuals from depressed patients without a history of
suicide attempts and from healthy individuals.
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Features of Suicide Attempters in Tehran, Iran: A Comparative Study. Med J Islam Repub Iran. 2024 (4 Nov);38:127.
https://doi.org/10.47176/mjiri.38.127
Introduction
In recent years, mental and public health experts have
been addressing the increasing prevalence of suicidal be-
havior among different age groups around the world (1).
This phenomenon not only affects families but also im-
poses significant economic and social costs on both devel-
oped and developing societies (2). In Iran, suicide behavior
is a major issue in terms of mental and public health (3). To
gain a better understanding of this issue, more research is
needed. However, based on several studies, despite the ef-
forts conducted by the Ministry of Health and other related
organizations (4-7), the rate of suicide is still on the rise,
making it one of the country's foremost health and social
concerns (7).
Suicide has a multifactorial etiology, including social, bi-
ological and companied mental disorders factors (8). Major
Depressive Disorder (MDD) is the most common psychiat-
ric disorder in suicide
attempters. Nevertheless, depression
cannot predict progression to suicide, nor can it be said that
all depressed people attempt suicide (9, 10). On the other
side, previous studies have indicated that there are differ-
ences in clinical variables between suicide attempters and
non-suicidal patients. Patients with at least one suicide at-
tempt are more frequently diagnosed with personality dis-
orders (18.5% vs 6.5%), have a higher frequency of hospi-
talization, have a longer duration of untreated illness, and
have a history of alcohol abuse. They also miss more work
hours and experience more general health problems com-
pared to those without a suicide attempt (11, 12).
Further studies have evaluated the neurocognitive mech-
anisms underlying cognitive impairments in individuals
with suicidal behaviors. In line with clinical findings, adult
attempters have shown that cognitive impairments can play
a significant role in this phenomenon (13-15), which can
provide insight into predicting the likelihood of suicidal be-
havior and also provide appropriate neurocognitive inter-
vention (8). A study (16) using the Cambridge Neuropsy-
chological Test Automated Battery (CANTAB) in youth
with and without suicidal behavior and ideation revealed
differences in some indicators such as response control, at-
tention, and problem-solving. The exploratory analysis dis-
covered that total commission errors on the Affective
Go/No-Go (AGN) test were not significant predictors of fu-
ture suicide attempts among females, as were higher strat-
egies scores on the Spatial Working Memory (SWM) test
for males. Interactions between neuropsychological char-
acteristics and social problems can influence the develop-
ment of suicide ideation (17). The ability to switch tasks
interaction with a negative social interface revealed that
distractibility was a significant predictor of suicide ideation
development in the future (OR = 3.45). Furthermore, there
is a significant difference in executive function (18), impul-
sivity (19), attention, and decision-making (20-22) between
depressed patients with a history of suicide attempts and
those with suicide ideations. Making decisions under ambi-
guity and risk was investigated using the Game of Dice
Task (GDT) and the Iowa Gambling Task (IGT). the results
showed that suicidal patients made more risky decisions
than non-suicidal patients and the healthy group, while no
differences were found between groups when it comes to
making decisions under ambiguity (22). In a longitudinal
study, there was a significant association between impair-
ment in spatial planning and working memory and previous
suicide attempts (OR = 8.810), which suggests that the as-
sociation between these cognitive features and suicidality
may persist over a long period of time (23). However, in
some contravening studies, there is not any significant dif-
ference between the cognitive characteristics of depressed
patients with and without suicide attempts and healthy con-
trols (18, 19, 24). These controversies may be related to the
proximity of attempting suicide or having a lifetime of sui-
cidal behaviors. Additionally, the differences in the tools
used to measure cognitive features can contribute to these
differences in results and findings (22, 25). More studies
are needed to clarify the clinical and neurocognitive fea-
tures of individuals with a history of suicidal behaviors.
This study aims to evaluate the neuropsychological and
clinical aspects among individuals with a very recent his-
tory of attempted suicide.
Methods
Participants
The study sample included 20 participants with major de-
pressive disorder who attempted suicide (SA+MDD), 21
participants with major depressive disorder (MDD) without
suicide attempt, and 21 healthy controls (HC) between ages
18 and 55 years old. The method of sampling was conven-
ient. Based on the calculation of the sample size using
G*Power software this sample size will be enough to have
80% Power for comparison of means between these three
dependent groups. Participants with SA+MDD were re-
cruited from the poisoning department of the Baharloo
Hospital. From 9 January 2021, the patients who were re-
ferred by the hospital psychiatrist were
selected by the clin-
ical psychologist in terms of inclusion criteria. The inclu-
sion criteria for patients who attempted suicide recently
(between 1 to 4 weeks ago) with concurrent diagnosis of a
major depressive disorder (MDD) according to the DSM-5
(SCID-5 for DSM-5, research version); and a score of 23 or
more in Beck Depression Inventory (BDI). Exclusion cri-
teria were diagnosis of psychotic or bipolar disorders, his-
tory of substance, alcohol, or drug abuse, a lifetime history
of severe head trauma or central nervous system disorder,
scores less than 15 (out of 30) points on the Beck Suicide
Intent Scale (BSI). MDD group, the participants were re-
ferred by psychiatrists from private or governmental out-
patient services. all the patients that met the criteria for cur-
rent major depressive episodes according to DSM-5 had a
score of 23 or more on the Beck Depression Inventory
(BDI) and had no personal and family history of suicidal
behavior enrolled in the study. Healthy controls required to
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have no previous or current psychiatric disorders and also
had no personal or family history of a suicide attempt. The
control group was selected from individuals who visited the
non-psychiatric clinic at Baharlu Hospital in an outpatient
setting. They were matched with the suicide group in terms
of age, gender, and education. These individuals were not
diagnosed with depression and suicidal thoughts through
SCID, BDI, and BSSI questionnaires. They also do not
have a history of suicide attempts in themselves or their
families.
Two clinical psychologists completed questionnaires as
part of the study. A PhD in clinical psychology adminis-
tered the clinical questionnaires, while a clinical psychol-
ogy expert conducted cognitive tests. After being dis-
charged from the hospital, patients were invited to the clinic
on two separate days to complete the questionnaires. The
clinical questionnaires were completed on the first day, and
the cognitive tests were performed on the second day. A
psychiatrist specializing in this field supervised all stages
of questionnaire completion.
Measures
The Structured Clinical Interview for DSM-5 (SCID-5):
SCID-5 is a semi-structured interview guide for the diag-
nosis of psychiatric disorders based on DSM-5 criteria and
is widely used in clinical settings (26). In one study (27)
that assessed the validity and reliability of Structured Clin-
ical Interview for DSM-5 – Clinician Version (SCID-5-
CV), this tool has an acceptable positive agreement be-
tween the interview and diagnoses (from 73 to 97 percent),
and the diagnostic sensitivity and specificity were above
0.70. The Persian version of SCID-5 has an acceptable in-
ternal consistency, test-retest reliability, and Kappa relia-
bility as 0.95-0.99, 0.60-0.79, and 0.57-0.72, respectively
(28).
Spielberger Anxiety State-Trait Inventory (STAI): The
STAI consists of 40 items and includes two separate parts,
which evaluate state and trait anxiety. 20 items evaluate
current (at this moment) anxiety and the other 20 items as-
sess how people “generally feel” about anxiety (29). This
inventory is graded on a four-point Likert scale. Abdoli et
al. (30) assessed the reliability and validity of the Persian
version of the State-Trait Anxiety Inventory Form Y
(STAI-Y) and the result showed that Cronbach's alpha for
internal consistency was 0.88 and 0.84 for trait and state
anxiety. Also, the convergent validity between BAI and
STAI-Y for state and trait anxiety was 0.64 and 0.61, re-
spectively.
Beck Depression Inventory (BDI-II): The BDI-II (31) is
a widely used tool to assess the severity of depression. It
consists of 21 items, and each statement is scored on a four-
point Likert scale. The total score ranges from 0 to 63 and
shows four degrees of severity such as minimal, mild, mod-
erate, and severe depression. The study (32) examined the
psychometric properties of a Persian version of BDI-II and
showed that this tool had high internal consistency
(Cronbach’s a ¼ 0.87) and acceptable test-retest reliability
(r ¼ 0.74) and had a strong correlation with the Automatic
Thoughts Questionnaire (ATQ). In this study, we used a
cut-off point of 23 to screen patients in terms of the severity
of depression.
Buss Perry Aggression Questionnaire (BPAQ): The
BPAQ developed by Arnold H. Buss and Mark Perry (33)
has 29 items and is scored on a five-point Likert scale. This
questionnaire evaluates a global measure of aggression and
four subscales of Physical Aggression, Verbal Aggression,
Anger, and Hostility. The psychometric properties of the
Persian version of BPAQ were assessed by Samani (34),
and the results showed appropriate test-retest reliability
(0.78). Also, all items except item 29 had a significant cor-
relation with the total score (range of 0.25 to 0.52). So,
these results confirm the efficiency of this questionnaire in
the Iranian sample.
Barratt’s Impulsivity Scale (BIS-11): The BIS-11 is a
self-report questionnaire of the personality/behavioral con-
struct of impulsiveness initially developed by Barratt (35)
in 1990. This scale consists of 30 items rated on a four-
point Likert scale, and the total score ranges from 30 to 120.
In one study (36) that investigated psychometric properties
of the Iranian version of the Barratt Impulsiveness Scale-
11, the findings showed three factors of non-planning im-
pulsivity, motor impulsivity, and cognitive impulsivity
were significantly correlated to the total score including 32
percent of the total variance. Also, in the evaluation of reli-
ability, Cronbach's alpha and test-retest were 0.81 and 0.77,
respectively. So, this study confirms that the BIS-11 scale
is usable for the Iranian sample.
Beck Scale for Suicidal Ideation (BSSI): The Self-report-
ing edition of BSSI (37) is a 19-item instrument that as-
sesses the severity of suicidal thoughts. The total score
ranges from 0 to 38, and a higher score indicates a greater
risk of suicide. In Iran (38), Cronbach's alpha coefficient of
the whole scale was 0.837, which showed high internal con-
sistency. Additionally, this scale had a positive correlation
with some indexes of SCL-90-R, such as depression and
Global Severity. So, the psychometric properties of the Per-
sian version of BSSI are approved for use in research set-
tings.
Beck Hopelessness Scale (BHS): The Beck Hopelessness
Scale is a self-report questionnaire Beck (39), assesses
three aspects of hopelessness, including loss of motivation,
expectations, and feelings about the future. This scale is
composed of 20 true-false items and the total score ranges
from 0 to 20. Psychometric properties of the Persian ver-
sion of the Beck Hopelessness Scale (40) have relatively
high reliability (r=0.70). In addition, Cronbach's alpha co-
efficient of the scale was 0.71, indicating high internal con-
sistency.
Reasons for Living Inventory (RFL): The RFL is a 48-
item inventory developed by Linehan et al. (41) that evalu-
ates factors that protect against the risk of suicide attempts.
This scale consists of 6 subscales, including Survival and
Coping Beliefs, Child-Related Concerns, Responsibility to
Family, Fear of Social Disapproval, Fear of Suicide, and
Moral Objections. Each reason is scored on a 6-point scale.
The Persian version of the RFL was standardized by
Mahmoudi et al. using an Iranian sample. The findings
showed that the test-retest coefficient and Cronbach's alpha
were 0.93 and 0.95, respectively (42).
The Beck Suicide Intent Scale (SIS): The Beck Suicide
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Intent Scale (SIS) is a 15-item scale developed to assess the
severity of suicidal intention (43). Studies support the reli-
ability of the scale, particularly the subscale that assesses
self-reported intention (versus circumstantial indicators)
(44).
Wechsler Adult Intelligence Scale (WAIS-R): The WAIS-
III (45) is a test of general intelligence and consists of 11
core subtests. Six of these subscales measure verbal abili-
ties, and five of them measure nonverbal mental abilities.
The scores include verbal, performance, and full-scale IQ.
In the Iranian study (46),
all subscales showed test-retest
reliability from 0.69 to 0.87, and their internal consistency
ranges from 0.77 to 0.88. In this study, we used a seven-
subtest short form (SF) conducted by Ward (1999). The in-
cluded subtests were Block Design (BD), Similarities (SI),
Digit Span (DS), Arithmetic (AR), Information (IN), Cod-
ing (CD), and Picture Completion (PC).
Cambridge Neuropsychological Test Automated Battery
(CANTAB): This computerized neuropsychological battery
developed by Sahakian and Robbins (47) at the University
of Cambridge measures three cognitive domains of: visual
memory, attention, and functional components of executive
function. In this study, using the Motor Screening Task
(MOT) at the beginning of the assessment, we introduced
the subtests to participants and ensured the validity of the
data by testing their sensorimotor and comprehension abil-
ities.
Procedure
The design of the study was a case–control study. The
study was approved by the Iran National Committee for
Ethics in Biomedical Research with the id of IR.NI-
MAD.REC.1398.158. It has been launched from 9 January
to November 2022 in Tehran, Iran. All the participants
signed an informed consent form before enrolling in the
study. Clinical interviews and neuropsychological assess-
ments were conducted by clinical psychologists, and self-
report questionnaires were completed by participants. All
these clinical procedures were performed under the super-
vision of a qualified senior psychiatrist.
Statistical analysis
We used mean, standard deviation (SD), and percentages
to describe the numeric and categorical variables respec-
tively. All numeric variables were tested with the nonpara-
metric Kolmogorov-Smirnov test to evaluate the normality
of distribution. To compare the quantitative variables
across three groups, we used Analysis of Variance
(ANOVA) for normal distribution variables and Kruskal-
Wallis for variables without normal distribution. We used
Dunnett as a post hoc test. We used the chi-square test to
compare categorical variables across three groups. We also
used correlation analysis to evaluate the association be-
tween clinical and neuropsychological variables. Statistical
analyses were performed by SPSS software (version 24)
with a significant level of 0.05.
Results
The demographic characteristics of SA+MDD and
MDD/HC groups were summarized in Table 1. There was
not any significant difference between the three groups
based on demographic characteristics.
Clinical evaluation
Table 2 illustrates the differences in clinical variables
across three groups. Kolmogorov-Smirnov test showed
normal distribution for all clinical variables. The mean of
hopelessness, anxiety (one month and lifetime), aggression,
and severity of MDD were worse in SA+MDD than MDD
group. The results of the post hoc test are shown in Table
3.
Neuropsychological evaluation
The Kolmogorov-Smirnov test revealed that 10 out of 19
subscales did not have a normal distribution. Therefore, the
Kruskal-Wallis one-way analysis of variances was used.
The one-way ANOVA test was used to compare the aver-
age scores of other neuropsychological tests that revealed a
normal distribution among the three groups (Table 4). Only
the variable "Scaled Score Similarities" showed a signifi-
Table 1. Demographic characteristics of study subjects
Demographic characteristic SA+MDD
No (%)
(n=20)
MDD
No (%)
(n=21)
HC
No (%)
(n=21)
P. Value
Gender Female 17 (32.7) 18 (34.6) 17 (32.7) 0.903
Male 3 (30) 3 (30) 4 (40) 0.903
Education (Years) <= 12 13 (41.9) 9 (29) 9 (29) 0.265
>12 7 (22.6) 12 (38.7) 12 (38.7) 0.265
Marital status Married 12 (33.3) 14 (38.9) 10 (27.8) 0.447
Unmarried 8 (30.8) 7 (26.9) 11 (42.3) 0.447
Employment status Employee 4 (16.7) 9 (37.5) 11 (45.8) 0.452
Housewife 8 (40) 7 (35) 5 (25) 0.452
Student 3 (60) 1 (20) 1 (20) 0.452
Unemployed 5 (38.5) 4 (30.8) 4 (30.8) 0.452
Handedness Right 17 (31.5) 19 (35.2) 18 (33.3) 0.506
Left 1 (20) 1 (20) 3 (60) 0.506
Equal 0 (0) 1 (100) 0 (0) 0.506
SA+MDD
Mean (SD)
MDD
Mean (SD)
HC
Mean (SD)
P. Value
Age 34.1 (±10.54) 35.9 (±10.38) 34 (±9.30) 0.791
IQ 84.44 (12.49) 98 (25.07) 91 (21.91) 0.138
*SA+MDD:Suicide Attempt+Major Depressive Disorder, MDD: Major Depressive Disorder, HC:Healthy Control
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cant difference (P=0.007) across the three groups. The re-
sults of the Dunnett test showed that there was a significant
difference in the "Scaled Score Similarities" between the
SA+MDD group and the MDD compared to the HC group
(P=0.009, P=0.003), respectively. There was no significant
difference between the MDD group and the HC group.
Correlation of clinical and neuropsychological variables
Significant associations were observed between clinical
and neuropsychological characteristics among individuals
who had attempted suicide(SA+MDD group). Regarding
the neuropsychological features, notable connections were
found as follows: Motor screening exhibited a significant
correlation with BIS (P<0.000), the Gambling test demon-
strated a significant correlation with SIS (P=0.045), Digit
span showed a significant correlation with BPAQ
(P=0.042), anxiety-springer-1 exhibited a marginally sig-
nificant correlation (P=0.075), and BDI showed a signifi-
cant correlation (P=0.000). The arithmetic task displayed a
significant correlation with SIS (P=0.004), BPAQ
(P=0.000), anxiety-springer-1 (P=0.033), and anxiety-
springer-2 (P=0.008). The block design task demonstrated
a significant correlation with SIS (P=0.002) and BPAQ
(P=0.030). Rapid Visual Information exhibited a signifi-
cant correlation with BIS (P=0.011), anxiety-springer-2
(P=0.042), and BDI (P=0.003). The digital symbol task dis-
played a significant correlation with BIS (P=0.029) and
BDI (P=0.008). Finally, the Picture Completion task exhib-
ited a significant correlation with BHS (P=0.042), demon-
strating a more negative/positive association with clinical
features(The details of the correlation table can be seen in
the Appendix).
Discussion
The evaluation of clinical variables among the three
groups (SA+MDD, MDD, and HC) revealed significant
differences. The results demonstrated that there was no sig-
nificant difference between the neuropsychological func-
tions of the three groups except the "Scaled Score Similar-
ities" of the SA+MDD, MDD, and HC groups, but the
MDD group and the HC group had no significant differ-
ence. Correlation results between clinical and neuropsy-
chological scales in the SA+MDD group are discussed be-
low.
There have been studies that have pointed to the crucial
Table 2. Comparison of clinical variables in three groups of study
Variances/ Groups SA+MDD
M (SD)
MDD
M(SD)
HC M(SD) F P. Value
BHS 14.94 (3.4) 12.7 (4.2) 3.8 (2.9) 55.44 <0.001
BSSI 23.83
(
5.51
)
7.8 (8.2) 0.43 (1.6) 64.19 <0.001
SIS 55.5 (10.5) 63.8 (9.3) 49.4 (9.8) * <0.001
RFL 112.7 (38.1) 183.7 (37.7) 214.5 (22.9) 46.50 <0.001
BPAQ 90.9 (17.3) 86.4 (15.9) 74.2 (22.6) 4.21 <0.001
STAI -1 64.4 (10.7) 61.9 (6.2) 39.5 (10.6) 39.03 <0.001
STAI -2 64.4 (8.4) 61.5 (9.2) 40 (9) 44.93 <0.001
BDI 22.8 (6) 21.1 (4.9) 3.5 (3.3) 101.17 <0.001
BHS: Beck Hopelessness Scale, SSI: Suicide Scale Ideation, RFL: Reason for Life, BPAQ: Buss Perry Aggression Questionnaire, STAI -1: Springer for Last Month,
STAI -2: Springer for Lifetime, BDI: Beck Depression Inventory.
* impulsivity (BIS) did not have a normal distribution, the P. value of the Kruskal-Wallis one-way analysis of variances was reported
Table 3. Post hoc analysis of clinical variables in three groups of study
Variable Group Mean diff. SE P. Value
BHS SA+MDD MDD 2.28 1.22 0.192
HC 11.18 1.01 <0.001
HC MDD -8.90 1.12 <0.001
BSSI SA+MDD MDD 15.99 2.29 <0.001
HC 23.40 1.37 <0.001
HC MDD -7.41 1.93 0.003
SIS SA+MDD MDD -8.31 3.20 0.041
HC 6.12 3.27 0.191
HC MDD -14.43 2.95 <0.001
RFL**
SA+MDD MDD -70.99 12.19 <0.001
HC -101.75 10.28 <0.001
HC MDD 30.76 9.63 0.009
BPAQ SA+MDD MDD 4.51 5.36 0.784
HC 16.80 6.41 0.037
HC MDD -12.28 6.04 0.139
Anxiety-springer-1
SA+MDD MDD 2.48 3.10 0.808
HC 24.86 3.43 <0.001
HC MDD -22.38 2.93 <0.001
Anxiety-springer-2
SA+MDD MDD 2.91 2.83 0.665
HC 24.29 2.79 <0.001
HC MDD -21.38 2.82 <0.001
BDI
SA+MDD MDD 1.69 1.77 0.716
HC 19.36 1.60 <0.001
HC MDD -17.67 1.29 <0.001
*SA+MDD:Suicide Attempt+Major Depressive Disorder, MDD: Major Depressive Disorder, HC:Healthy Control
** A higher score indicates a higher level of reason for life
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role of hopelessness, anger, and impulsivity in suicide at-
tempts (48-51). However, the results of this study showed
just significant differences in RFL between SA/MDD and
the other two control groups. Additionally, although hope-
lessness score, there was significant difference between
groups. However, the SA+MDD scores were higher than
the other two groups. These may indicate that the suicide
attempters in this study rather than impulsive acting out the
suicide urge , were more hopeless. Suicide attempts may
motivated by impulsive behavior or hopelessness the latest
one should be considered more serious for re-attempt (52,
53). Studies have indicated that individuals who engage in
non-impulsive suicide attempters experience a greater in-
tensity of suicidal thoughts compared to those who act im-
pulsively (54).in our study, the subjects were recruited from
individuals who attempted suicide in the last four weeks
and who may have the intention to die or re-attempt.
SA+MDD group had a significantly lower score in reason
for life compared to the MDD and HC groups. According
to the Interpersonal Theory of Suicide, suicidal behavior
arises from the combination of two factors: perceived bur-
densomeness. When individuals experience both perceived
burdensomeness and thwarted belongingness, they may
lose their reasons for life, which may lead to an increased
risk of suicidal ideation and attempts (55, 56). In addition,
the RFL scale showed positive associations with certain
protective factors of suicide. These factors include control
over goal attainment through strategies that involve con-
necting with others in the social environment, positive fam-
ily relationships, and community-level resilience factors
(57). The lower RFL scale score in the suicide group, may
indicate a lack of certain protective factors against suicide,
which has led them to attempt suicide.
We also investigated cognitive functions among three
groups of people. Unexpectedly , the results for most of the
investigated cognitive components did not significantly dif-
fer between the three groups, while some studies that used
neuropsychological batteries were able to find a significant
difference between suicidal and non-suicidal individuals
(58, 59). However, for some components, such as the mo-
tor screening task mean latency, emotional cognitive recog-
nition and spatial working memory, although the difference
is not statistically significant, the difference in the scores of
the SA+MDD and MDD groups and HC groups can be con-
sidered. Although the IQ of the two groups was largely sim-
ilar, the lack of differences between the groups in the neu-
ropsychological scales could be attributed to various fac-
tors, such as the length of the tests and the fatigue of the
participants, and the small sample size.
Nonetheless, there are other hypotheses that could be
proposed and investigated in future studies. One hypothesis
suggests that individuals in a crisis of suicide attempt may
temporarily experience heightened cognitive performance,
aiding them in non-efficient planning and attempting sui-
cide. Essentially, they may utilize their cognitive functions,
such as planning, instead of addressing solving life prob-
lems to alleviate psychological pain and attempt suicide
(59). Given that the individuals in the suicide group in our
study had attempted suicide recently (one month ago), this
hypothesis could be further explored in future studies.
Despite the absence of significant differences in cogni-
tive performance among the three groups (SA+MDD,
MDD, and HC), the focus was placed on exploring the cor-
relation between cognitive and clinical factors. This inves-
tigation aimed to understand the relationship and mutual in-
fluence of these factors. However, there were some inter-
esting points in the correlation between clinical and neuro-
psychological scales in the suicide group. Results revealed
a positive correlation between the Suicidal Ideation Scale
(SSI) and Motor Screening Task (MOT). The MOT as-
sesses sensory motor skills as well as impulse control. Ad-
ditionally, the SSI showed a significant positive relation-
ship with the impulsivity scale (BIS). Therefore, as suicidal
thoughts increase in individuals at risk of suicide, impulsive
Table 4. Comparison of neuropsychological variables in three groups of study
Variables/Groups SA+MDD
Mean (SD)
MDD
Mean (SD)
HC
Mean (SD)
F P.
value
Motor Screening Task Mean latency 783.82 (203.15) 739.24 (168.00) 722.06 (129.02) * 0.720
Motor Screening Task Mean error 9.90 (2.88) 9.33 (2.34) 10.34 (2.65) 0.790 0.459
Emotion Recognition Task Percent correct 57.71 (8.80) 57.65 (9.86) 63.81 (10.35) 0.64
Emotion Recognition Task Mean overall response la-
tency
2832.72 (977.58) 2859.92
(739.37)
3070.09
(820.05)
0.480 0.621
Cambridge Gambling Task Risk adjustment 0.47 (0.93) 0.34 (0.81) 0.18 (1.36) 0.350 0.706
Cambridge Gambling Task Risk-taking 0.50 (0.12) 0.51 (0.10) 0.47 (0.15) 0.644 0.529
Rapid Visual Information Processing Mean latency 607.63 (178.51) 513.25 (150.44) 579.02 (187.18) * 0.168
Rapid Visual Information A' 0.85 (0.08) 0.84 (0.05) 0.87 (0.05) * 0.247
Rapid Visual Information Total hits 11.00 (5.17) 13.90 (6.16) 13.87 (6.44) 1.467 0.239
Rapid Visual Information Total false alarms 4.39 (7.40) 4.48 (6.99) 7.09 (12.16) * 0.446
Spatial Working Memory Between Errors 35.35 (22.11) 31.95 (22.23) 39.09 (23.26) * 0.576
Spatial Working Memory Strategy 35.82 (5.88) 35.04 (5.62) 37.09 (4.88) 0.754 0.475
Scaled Score digit span 6.72 (2.37) 7.28 (2.28) 7.33 (2.15) * 0.723
Scaled Score Arithmetic 7.44 (2.33) 8.23 (2.48) 7.76 (2.11) 0.584 0.561
Scaled Score Block Design 9.00 (2.44) 9.19 (2.71) 8.80 (2.80) 0.107 0.899
Scaled Score Digital Symbol 8.83 (2.30) 9.09 (2.58) 9.47 (2.11) * 0.646
Scaled Score Similarities 7.68 (1.49) 9.90 (2.68) 10.42 (2.77) * 0.007
Scaled Score picture completion 6.87 (2.78) 8.76 (2.99) 8.05 (2.65) 2.037 0.141
Scaled Score information 6.87 (2.39) 8.14 (2.08) 8.73 (2.84) * 0.130
*These subscales did not have a normal distribution, the P. value of the Kruskal-Wallis one-way analysis of variances was reported (Motor screening Task Mean latency,
Emotion Recognition Task Percent correct, Rapid Visual Information Processing Mean latency, Rapid Visual Information A' target sensitivity, Rapid Visual Information
Total false alarms, Spatial Working Memory Between errors, Scaled Score digit span, Scaled Score Digital Symbol, Scaled Score Similarities, Scaled Score information).
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behaviors also tend to increase. Consistent with our find-
ings, previous studies have also demonstrated a link be-
tween suicidal thoughts and impulsivity (60, 61). In addi-
tion, there was a significant positive relationship between
the Beck Intension Scale (SIS) and the Cambridge gam-
bling task risk-taking. The Cambridge gambling task risk-
taking assesses decision-making and risk-taking behavior
(62). Therefore, this relationship suggests that individuals
with higher levels of suicidal intention are more inclined to
take risks, which in turn increases their likelihood of at-
tempting suicide. Risk-taking behavior is related to the ven-
tromedial frontal area and anterior cingulate which are re-
sponsible areas for evaluating risk and making decisions
(63). Studies have shown that there is an impairment in
these areas among suicidal individuals (64).
Additionally, the Symbol Digit subscale exhibited a neg-
ative correlation with the levels of aggression and depres-
sion. A high score on the Symbol Digit subscale suggests
proficient motor speed and attention (65). Our findings in-
dicate that within the suicide group, the severity of depres-
sion and aggression is directly proportional to the impair-
ment in motor speed and attention. Shifting attention and
motor speed are related to the frontal and the neural circuit
of fronto-striato-thalamo cortex, which reveals that mal-
function of these circuits may contributed to the neural dys-
function of suicidal cases (66).
Our study sample attempted suicide in the last four weeks
and may have the intention to re-attempt, which may be
deemed in this result. Individuals who have recently at-
tempted suicide exhibit a greater inclination to engage in
risky behaviors (67, 68).
Our results showed that the digit span scale has a signif-
icant negative relationship with the BPAQ, the anxiety-
springer, and the BDI. Given that the digit span scale as-
sesses working memory and attention (69), this relationship
suggests that individuals with higher levels of aggression,
anxiety, and depression tend to have lower working
memory performance, which is related to frontal lobe func-
tion (70). Previous studies have also shown deficits in
working memory among suicidal patients (71). Other evi-
dence has shown that working memory acts as a mediator
for aggression in individuals who have been raised in an
inappropriate environment (72, 73). In addition, working
memory is one of the functions of the frontal lobe, and there
is ample evidence indicating that this function is impaired
in suicidal patients (74, 75). In this direction, within the su-
icidal group, the arithmetic subscale also exhibits a nega-
tive correlation with the suicidal intention scale, the BPAQ,
and the anxiety-springer scale. In the sense that the arith-
metic subscale assesses numerical reasoning ability, atten-
tion, and concentration (76), these results can be considered
as confirming the findings mentioned above. On the other
hand, the same clinical subscales of aggression, anxiety,
and intention to suicide (SIS) exhibit a negative correlation
with the Block Design subscale. The Block Design subscale
also demonstrates abilities in visual memory, executive
function, and processing speed which is more related to pa-
rietal function (77, 78). Some studies have indicated that
improvement in visual memory among individuals at risk
of suicide was associated with a decrease in suicide risk
(79). Additionally, these studies discovered that poor per-
formance in processing speed was associated with a higher
risk of suicide (79).
In the suicide group, the picture completion scale showed
a significant positive correlation with Beck's Hopelessness
Scale (BHS). The completion scale assesses the ability to
recognize and attend to details (80). Previous studies have
indicated that a positive mood is associated with decreased
attention to detail and cognitive effort. Therefore, it can be
hypothesized that individuals experiencing depression ex-
hibit heightened attention to negative details, which may
contribute to a greater sense of hopelessness (81). In addi-
tion, the emotion recognition scale showed a significant
positive correlation with the clinical scales measuring sui-
cidal thoughts and anxiety. Emotion recognition scales as-
sess two key aspects of the ability to recognize emotions:
the accuracy in identifying the types of emotions that com-
pose a person's emotional state and the sensitivity to the in-
tensity of those emotions (82). Therefore, this positive cor-
relation suggests that in suicidal patients, with the increase
in suicidal thoughts and anxiety, the sensitivity to the inten-
sity of other people's emotions increases. Some studies
have shown that individuals who are depressed and have
suicidal thoughts may have a heightened ability to recog-
nize unpleasant emotions, such as fear, compared to de-
pressed individuals without suicidal thoughts (83).
Conclusion
Neuropsychological findings are inconsistent among
studies, which may be attributed to their clinical features
and the dominancy of hopelessness or impulsivity. Limited
significant differences between SA/MDD and MDD could
be the sample size and also recently attempted which, in our
studies, the suicidal subjects were recruited from those who
attempted in the last four weeks who are at risk of re-at-
tempt again (84, 85). functional impairment of the frontal,
parietal, and temporal gyrus could have implications for the
brain function of individuals with recent suicide attempts
who are at risk of re-attempt.These findings shed light on
the complex interplay between clinical variables and cog-
nitive functions in individuals at risk of suicide emphasiz-
ing the need for comprehensive evaluations and targeted in-
terventions that can inform the development of tailored
treatment approaches.
Authors’ Contributions
Mozhgan Taban: Review of statistical analyses, revision
and critique of the manuscript, interpretation of results;
Seyed Kazem Malakouti: Research study conception and
design, organization of study data, review of statistical
analyses, revision and critique of the manuscript, interpre-
tation of results; Negar Bastani: Collecting data, critique of
the manuscript; Marzieh Nojomi: Statistical analysis, revi-
sion; Vahid Sadeghi-Firoozabadi: Critique of the manu-
script; Ehsan Rajabi: Research study conception, revision;
and Nafee Rasouli: Collecting data, organization of study
data, review of statistical analyses, revision and critique of
the manuscript, interpretation of results.
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Ethical Considerations
The present study will commence after obtaining the
code of ethics from the Ethics Committee of the National
Institute of Medical Sciences Research Development (NI-
MAD). Participants were fully informed about all stages of
the study, and written consent was obtained before begin-
ning. In the written consent, participants were informed that
their personal information would be protected.
Acknowledgment
We thank all participants for their contribution to this re-
search study.
Conflict of Interests
The authors declare that they have no competing interests.
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Clinical and Neuropsychological Features of Suicide Attempt
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10
Appendix. Correlation analysis between clinical and neuropsychological variables in the SA+ MDD group
Group Motor
screen-
ing Task
Mean la-
tency
Emotion
Recognition
Task Per-
cent correct
Cambridge
Gambling
Task Risk-
taking
Rapid Vis-
ual Infor-
mation To-
tal false
alarms
Scaled
Score
digit
span
Scaled
Score
Arithme-
tic
Scaled
Score
Block
De-
sign
Scaled
Score
Digital
Sym-
bol
Scaled
Score Sim-
ilarities
Scaled
Score pic-
ture com-
pletion
Scaled
Score in-
formation
SA+MDD SIS Pearson Corre-
lation
0.329 0.038 .477
*
0.148 -0.401 -.642
**
-.680
**
-0.366 -0.141 0.196 -0.095
Sig. (2-tailed) 0.183 0.882 0.045 0.557 0.099 0.004 0.002 0.135 0.603 0.467 0.726
PDI Pearson Corre-
lation
0.406 -0.040 0.210 -0.156 -0.333 -0.458 -0.188 -0.207 -0.158 -0.034 -0.232
Sig. (2-tailed) 0.094 0.876 0.404 0.535 0.176 0.056 0.454 0.410 0.560 0.901 0.387
BHS Pearson Corre-
lation
0.364 0.166 -0.141 0.301 -0.186 -0.131 -0.093 -0.190 0.013 .513
*
-0.258
Sig. (2-tailed) 0.137
0.509
0.577
0.225
0.460
0.603 0.715 0.449 0.962 0.042
0.336
BSSI Pearson Corre-
lation
0.464 0.451 0.139 0.123 -0.440 -0.452 -0.292 -0.229 0.235 -0.180 -0.029
Sig. (2-tailed) 0.053 0.060 0.582 0.627 0.067 0.060 0.240 0.361 0.381 0.504 0.916
BIS Pearson Corre-
lation
.747
**
0.012 -0.158 .582
*
-0.282 -0.332 -0.153 -.514
*
-0.047 -0.063 -0.372
Sig. (2-tailed) 0.000 0.963 0.532 0.011 0.256 0.179 0.544 0.029 0.862 0.817 0.156
RFL Pearson Corre-
lation
-0.253 -0.363 0.026 -0.199 0.329 -0.009 0.008 -0.056 -0.087 -0.021 0.045
Sig. (2-tailed)
0.310 0.139 0.917 0.428 0.182 0.971 0.974 0.825 0.749 0.938 0.868
BPAQ Pearson Corre-
lation
0.376 0.059 0.283 0.305 -.484
*
-.638
**
-.511
*
-0.383 -0.308 -0.433 -0.019
Sig. (2-tailed) 0.125 0.815 0.254 0.218 0.042 0.004 0.030 0.117 0.246 0.093 0.944
anxiety-
springer-
1
Pearson Corre-
lation
0.258 0.466 -0.190 0.417 -0.430 -.503
*
-.483
*
-0.256 -0.214 0.014 -0.257
Sig. (2-tailed) 0.301 0.051 0.451 0.085 0.075 0.033 0.042 0.305 0.425 0.958 0.338
anxiety-
springer-
2
Pearson Corre-
lation
0.124 0.182 -0.255 .483
*
-.575
*
-.603
**
-0.326 -0.166 -0.065 -0.011 -0.189
Sig. (2-tailed) 0.623 0.469 0.308 0.042 0.012 0.008 0.187 0.510 0.811 0.969 0.484
BDI Pearson Corre-
lation
0.286 -0.078 0.031 .661
**
-.633
**
-0.283 -0.227 -.602
**
-0.250 0.087 -0.226
Sig. (2-tailed) 0.250 0.759 0.902 0.003 0.005 0.255 0.365 0.008 0.351 0.749 0.400
[ DOI: 10.47176/mjiri.38.127 ] [ Downloaded from mjiri.iums.ac.ir on 2024-12-15 ]
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