Abstract
Although suicide is a pervasive public health issue, strong predictors of suicidal thoughts and behaviors (STBs, e.g., passive or active suicidal ideation, suicide plans, suicide attempts, etc.) are lacking. Theory suggests that attentional processes, such as attentional bias and attentional control, may contribute to STBs. Specifically, among individuals with suicidal ideation, attentional biases towards suicide-related information may increase distress. This combined with the inability to disengage and shift attention away from suicidal thoughts (i.e., deficits in attentional control) might contribute to increased risk for negative outcomes (i.e., non-suicidal self-injury, suicidal behavior). Despite this notion, there has been limited research examining associations between attentional risk factors and STBs. Therefore, the purpose of this study was to conduct a meta-analysis to examine possible associations between attentional biases and STBs and attentional control and STBs. A comprehensive literature search was conducted and a total of 20 articles were retained for this meta-analysis. A small, but significant relationship was observed between attentional bias and STBs (r = .09, 95% CI: .06, .13), but not attentional control and STBs (r = -.04, 95% CI: -.21, .12). The limited number of studies identified, and therefore low power, precluded moderator analyses from being conducted. Moreover, additional experimental and longitudinal research with diverse assessments of attentional risk factors is needed. Despite these limitations, the present study provides preliminary evidence for the association between attentional bias and STBs.
Similar content being viewed by others
Data Availability
The data used to produce these results is available upon request from the corresponding author.
Notes
Two studies that measured the association between attentional control and STBs were comprised of samples that had psychotic or schizophrenia diagnoses. To ensure that these studies did not unduly influence the current findings, we removed them, and reexamined the association between attentional control and STBs. The pattern of results remained the same. A nonsignificant effect was observed for the association between attentional control and STBs (r = -.08, 95% CI: -.29, .14) and there was high heterogeneity in the effect (Q = 62.11, p < .001, I2 = 87.12%).
References
*Study was included in the meta-analytic results
Abramson, L. Y., Alloy, L. B., Hogan, M. E., Whitehouse, W. G., Gibb, B. E., Hankin, B. L., & Cornette, M. M. (2002). The hopelessness theory of STBs. In Suicide Science (pp. 17–32). Springer, Boston, MA.
Adler, A., Jager-Hyman, S., Green, K. L., Brown, G. K., Beck, A. T., & Wenzel, A. (2015). Initial psychometric properties of the attentional fixation on suicide experiences questionnaire. Cognitive Therapy and Research, 39, 492–498.
Badura-Brack, A. S., Naim, R., Ryan, T. J., Levy, O., Abend, R., Khanna, M. M., ... & Bar-Haim, Y. (2015). Effect of attention training on attention bias variability and PTSD symptoms: randomized controlled trials in Israeli and US combat veterans. American Journal of Psychiatry, 172(12), 1233–1241.
*Baghani, E., Fata, L., Salehi, M., & Hasani, F. (2020). Attentional bias and prediction of attempted suicide in clinical and non-clinical population. Practice in Clinical Psychology, 8(3), 243–256.
Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & Van Ijzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin, 133(1), 1–24.
Bardeen, J. R., & Daniel, T. A. (2017). A longitudinal examination of the role of attentional control in the relationship between posttraumatic stress and threat-related attentional bias: An eye-tracking study. Behaviour Research and Therapy, 99, 67–77.
Bardeen, J. R., Daniel, T. A., Gordon, R. D., Hinnant, J. B., & Weathers, F. W. (2020). Individual differences in attentional control explain the differential expression of threat-related attentional bias among those with posttraumatic stress symptomatology and predict symptom maintenance up to one year later. Behaviour Research and Therapy, 133, 103709.
Bardeen, J. R., & Read, J. P. (2010). Attentional control, trauma, and affect regulation: A preliminary investigation. Traumatology, 16(3), 11–18.
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. Basic Books.
*Becker, E. S., Strohbach, D., & Rinck, M. (1999). A specific attentional bias in suicide attempters. The Journal of Nervous and Mental Disease, 187(12), 730–735.
*Burton, C. Z., Vella, L., Weller, J. A., & Twamley, E. W. (2011). Differential effects of executive functioning on suicide attempts. The Journal of Neuropsychiatry and Clinical Neurosciences, 23(2), 173–179.
Carlson, J. M. (2021). A systematic review of event-related potentials as outcome measures of attention bias modification. Psychophysiology, 58(6), e13801.
Centers for Disease Control and Prevention. (2022). National Center for Injury Prevention and Control. Suicide Prevention. https://www.cdc.gov/suicide/index.html
Cha, C. B., Najmi, S., Amir, N., Matthews, J. D., Deming, C. A., Glenn, J. J., ... & Nock, M. K. (2017). Testing the efficacy of attention bias modification for suicidal thoughts: Findings from two experiments. Archives of Suicide Research, 21(1), 33–51.
*Cha, C. B., Najmi, S., Park, J. M., Finn, C. T., & Nock, M. K. (2010). Attentional bias toward suicide-related stimuli predicts suicidal behavior. Journal of Abnormal Psychology, 119(3), 616.
*Chung, Y., & Jeglic, E. L. (2016). Use of the modified emotional Stroop task to detect STBs in college population. Suicide and Life-Threatening Behavior, 46(1), 55–66.
Clauss, K., Bardeen, J. R., Gordon, R. D., & Daniel, T. A. (2021). Increasing cognitive load attenuates the moderating effect of attentional inhibition on the relationship between posttraumatic stress symptoms and threat-related attention bias variability. Journal of Anxiety Disorders, 81, 102416.
Clauss, K., Gorday, J. Y., & Bardeen, J. B. (2022). Eye-tracking evidence of threat-related attentional bias in anxiety- and fear-related disorders: A systematic review and meta-analysis. Clinical Psychology Review, 93, 102142.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences 2nd ed Hillsdale NJ Erlbaum.
Copas, J., & Shi, J. Q. (2000). Meta-analysis, funnel plots and sensitivity analysis. Biostatistics, 1(3), 247–262.
Cristea, I. A., Kok, R. N., & Cuijpers, P. (2015). Efficacy of cognitive bias modification interventions in anxiety and depression: Meta-analysis. British Journal of Psychiatry, 206(1), 7–16.
De Ruiter, C., & Brosschot, J. F. (1994). The emotional Stroop interference effect in anxiety: Attentional bias or cognitive avoidance? Behaviour Research and Therapy, 32(3), 315–319.
*Delaney, C., McGrane, J., Cummings, E., Morris, D. W., Tropea, D., Gill, M., ... & Donohoe, G. (2012). Preserved cognitive function is associated with suicidal ideation and single suicide attempts in schizophrenia. Schizophrenia Research, 140(1–3), 232–236.
Dennis-Tiwary, T. A., Roy, A. K., Denefrio, S., & Myruski, S. (2019). Heterogeneity of the anxiety-related attention bias: A review and working model for future research. Clinical Psychological Science, 7(5), 879–899.
*Dickhoff, J., Opmeer, E. M., Heering, H. D., Bruggeman, R., van Amelsvoort, T., Bartels-Velthuis, A. A., ... & van Tol, M. J. (2021). Relationship between social cognition, general cognition, and risk for suicide in individuals with a psychotic disorder. Schizophrenia Research, 231, 227–236.
Eide, P., Kemp, A., Silberstein, R. B., Nathan, P. J., & Stough, C. (2002). Test-retest reliability of the emotional Stroop task: Examining the paradox of measurement change. The Journal of Psychology, 136(5), 514–520.
Eysenck, M. W., Derakshan, N., Santos, R., & Calvo, M. G. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7, 336.
Field, A. P., & Gillett, R. (2010). How to do a meta-analysis. British Journal of Mathematical and Statistical Psychology, 63(3), 665–694. https://doi.org/10.1348/000711010X502733
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., ... & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187.
Funder, D. C., & Ozer, D. J. (2019). Evaluating effect size in psychological research: Sense and nonsense. Advances in Methods and Practices in Psychological Science, 2(2), 156–168.
Gotlib, I. H., & Joormann, J. (2010). Cognition and depression: Current status and future directions. Annual Review of Clinical Psychology, 6, 285–312.
Hak, T., van Rhee, H., & Suurmond, R. (2016). How to interpret results of meta-analysis. Available at SSRN 3241367.
Hedges, L. V., & Olkin, I. (1985). Statistical Methods for Meta-Analysis. Academic Pres. Inc.
*Herzog, S., Keilp, J. G., Galfalvy, H., Mann, J. J., & Stanley, B. H. (2023). Attentional control deficits and suicidal ideation variability: An ecological momentary assessment study in major depression. Journal of Affective Disorders, 323, 819–825.
Higgins, J. P. T., & Thompson, S. G. (2002). Quantifying heterogeneity in a meta-analysis. Statistics in Medicine, 21(11), 1539–1558. https://doi.org/10.1002/sim.1186
Hoaglin, D. C. (2016). Misunderstandings about Q and ‘Cochran's Q test'in meta analysis. Statistics in Medicine, 35(4), 485–495.
Hsu, K. J., Beard, C., Rifkin, L., Dillon, D. G., Pizzagalli, D. A., & Björgvinsson, T. (2015). Transdiagnostic mechanisms in depression and anxiety: The role of rumination and attentional control. Journal of Affective Disorders, 188, 22–27.
*Interian, A., Myers, C. E., Chesin, M. S., Kline, A., Hill, L. S., King, A. R., ... & Keilp, J. G. (2020). Towards the objective assessment of suicidal states: Some neurocognitive deficits may be temporally related to suicide attempt. Psychiatry Research, 287, 112624.
*Keilp, J. G., Gorlyn, M., Oquendo, M. A., Burke, A. K., & Mann, J. J. (2008). Attention deficit in depressed suicide attempters. Psychiatry Research, 159(1–2), 7–17.
*Keilp, J. G., Gorlyn, M., Russell, M., Oquendo, M. A., Burke, A. K., Harkavy-Friedman, J., & Mann, J. J. (2013). Neuropsychological function and suicidal behavior: Attention control, memory and executive dysfunction in suicide attempt. Psychological Medicine, 43(3), 539–551.
Khanna, M. M., Badura-Brack, A. S., McDermott, T. J., Shepherd, A., Heinrichs-Graham, E., Pine, D. S., ... & Wilson, T. W. (2016). Attention training normalises combat-related post-traumatic stress disorder effects on emotional Stroop performance using lexically matched word lists. Cognition and Emotion, 30(8), 1521–1528.
Khoshdel, A., Attia, J., & Carney, S. L. (2006). Basic concepts in meta-analysis: A primer for clinicians. International Journal of Clinical Practice, 60(10), 1287–1294.
Kleiman, E. M., & Nock, M. K. (2018). Real-time assessment of suicidal thoughts and behaviors. Current Opinion in Psychology, 22, 33–37.
Klonsky, E. D., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8(2), 114–129.
Koster, E. H., De Lissnyder, E., Derakshan, N., & De Raedt, R. (2011). Understanding de- pressive rumination from a cognitive science perspective: The impaired disengagement hypothesis. Clinical Psychology Review, 31, 138–145.
Lalovic, A., Wang, S., Keilp, J. G., Bowie, C. R., Kennedy, S. H., & Rizvi, S. J. (2022). A qualitative systematic review of neurocognition in suicide ideators and attempters: Implications for cognitive-based psychotherapeutic interventions. Neuroscience & Biobehavioral Reviews, 132, 92–109.
Lazarov, A., Suarez-Jimenez, B., Abend, R., Naim, R., Shvil, E., Helpman, L., ... & Neria, Y. (2019a). Bias-contingent attention bias modification and attention control training in treatment of PTSD: a randomized control trial. Psychological Medicine, 49(14), 2432–2440.
Lazarov, A., Suarez-Jimenez, B., Tamman, A., Falzon, L., Zhu, X., Edmondson, D. E., & Neria, Y. (2019b). Attention to threat in posttraumatic stress disorder as indexed by eye-tracking indices: A systematic review. Psychological Medicine, 49(5), 705–726.
*LeGris, J., Links, P. S., van Reekum, R., Tannock, R., & Toplak, M. (2012). Executive function and suicidal risk in women with Borderline Personality Disorder. Psychiatry Research, 196(1), 101–108.
Lin, L., Liu, Y., Mo, J., Wang, C., Liu, T., Xu, Z., ... & Wu, X. (2022). Attentional bias to emotional facial expressions in undergraduates with suicidal ideation: An ERP study. Archives of Suicide Research, 1–18.
Lipsey, M. W., & Wilson, D. B. (2001). Practical meta-analysis (Vol. 49). Sage Publications Thousand Oaks, CA.
*Loyo, L. M. S., Martínez-Velázquez, E. S., & Ramos-Loyo, J. (2013). Influence of emotions on executive functions in suicide attempters. Suicidology, 4(1), 42–55.
*Malloy-Diniz, L. F., Neves, F. S., Abrantes, S. S. C., Fuentes, D., & Corrêa, H. (2009). Suicide behavior and neuropsychological assessment of type I bipolar patients. Journal of Affective Disorders, 112(1–3), 231–236.
Mandel, A. A., Revzina, O., Jessani, Z., & Brown, G. K. (2022). Revised Attentional Fixation on Suicide Experiences Questionnaire and its relationship with suicidal ideation and behavior: A cross-sectional study. Suicide and Life-Threatening Behavior, 52(6), 1096–1109.
May, A. M., & Klonsky, E. D. (2016). What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clinical Psychology: Science and Practice, 23(1), 5.
Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A., & Wager, T. D. (2000). The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A latent variable analysis. Cognitive Psychology, 41(1), 49–100.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, T. P. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLOS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097
Moreno, M., Guitérrez-Rojas, L., & Porras-Segovia, A. (2022). Implicit cognition tests for the assessment of suicide risk: A systematic review. Current Psychiatry Reports, 1–19.
Moscardini, E. H., Aboussouan, A. B., Bryan, C. J., & Tucker, R. P. (2020). Suicide-specific cognitions, attentional fixation, and worst-point suicidal ideation. Suicide and Life-Threatening Behavior, 50(4), 899–908.
*Moscardini, E. H., & Tucker, R. P. (2023). Psychometric properties of an online administered version of the suicide stroop task. Journal of Psychopathology and Behavioral Assessment, 45(1), 122–135.
Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30(1), 133–154.
Nock, M. K., Kessler, R. C., & Franklin, J. C. (2016). Risk factors for suicide ideation differ from those for the transition to suicide attempt: The importance of creativity, rigor, and urgency in suicide research. Clinical Psychology Science and Practice, 23, 31–34.
O’Bryan, E. M., Kraemer, K. M., Johnson, A. L., McLeish, A. C., & McLaughlin, L. E. (2017). Examining the role of attentional control in terms of specific emotion regulation difficulties. Personality and Individual Differences, 108, 158–163.
O’Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational–volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society b: Biological Sciences, 373(1754), 20170268.
Peckham, A. D., McHugh, R. K., & Otto, M. W. (2010). A meta-analysis of the magnitude of biased attention in depression. Depression and Anxiety, 27(12), 1135–1142.
*Richard-Devantoy, S., Annweiler, C., Le Gall, D., Garré, J. B., Olié, J. P., & Beauchet, O. (2011). Cognitive inhibition in suicidal depressed elderly: A case-control pilot study. The Journal of Clinical Psychiatry, 72(6), 3189.
*Richard-Devantoy, S., Ding, Y., Turecki, G., & Jollant, F. (2016). Attentional bias toward suicide-relevant information in suicide attempters: A cross-sectional study and a meta-analysis. Journal of Affective Disorders, 196, 101–108.
Rogers, M. L., & Joiner, T. E. (2017). Rumination, suicidal ideation, and suicide attempts: A meta-analytic review. Review of General Psychology, 21(2), 132–142.
*Rosario-Williams, B., Akter, S., Kaur, S., & Mirada, R. (2023). Suicide-related construct accessibility and attention disengagement bias in suicide ideation. Journal of Psychopathology and Clinical Science, 132(2), 173.
Rosenthal, R., & DiMatteo, M. R. (2001). Meta-analysis: Recent developments in quantitative methods for literature reviews. Annual Review of Psychology, 52(1), 59–82.
Rothstein, H. R. (2008). Publication bias as a threat to the validity of meta-analytic results. Journal of Experimental Criminology, 4(1), 61–81.
Sarapas, C., Weinberg, A., Langenecker, S. A., & Shankman, S. A. (2017). Relationships among attention networks and physiological responding to threat. Brain and Cognition, 111, 63–72.
Schafer, K. M., Kennedy, G., Gallyer, A., & Resnik, P. (2021). A direct comparison of theory-driven and machine learning prediction of suicide: A meta-analysis. PLoS ONE, 16(4), e0249833.
Schmidt, N. B., Norr, A. M., Allan, N. P., Raines, A. M., & Capron, D. W. (2017). A randomized clinical trial targeting anxiety sensitivity for patients with suicidal ideation. Journal of Consulting and Clinical Psychology, 85(6), 596.
Shackman, A. J., Stockbridge, M. D., Tillman, R. M., Kaplan, C. M., Tromp, D. P., Fox, A. S., & Gamer, M. (2016). The neurobiology of dispositional negativity and attentional biases to threat: Implications for understanding anxiety disorders in adults and youth. Journal of Experimental Psychopathology, 7(3), 311–342.
Shi, R., Sharpe, L., & Abbott, M. (2019). A meta-analysis of the relationship between anxiety and attentional control. Clinical Psychology Review, 72, 101754.
Strauss, G. P., Allen, D. N., Jorgensen, M. L., & Cramer, S. L. (2005). Test-retest reliability of standard and emotional Stroop tasks: An investigation of color-word and picture-word versions. Assessment, 12(3), 330–337.
Tavakoli, P., Jerome, E., Boafo, A., & Campbell, K. (2021). Attentional bias deficits in adolescent suicide attempters during an emotional Stroop task: An ERP study. Frontiers in Psychiatry, 12, 694147.
Theeuwes, J. (1993). Visual selective attention: A theoretical analysis. Acta Psychologica, 83(2), 93–154.
*Thompson, C., & Ong, E. L. C. (2018). The association between suicidal behavior, attentional control, and frontal asymmetry. Frontiers in Psychiatry, 9, 79.
Van Aert, R. C., Wicherts, J. M., & van Assen, M. A. (2016). Conducting meta-analyses based on p values: Reservations and recommendations for applying p-uniform and p-curve. Perspectives on Psychological Science, 11(5), 713–729.
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575.
Wastler, H. M., Bryan, A. O., & Bryan, C. J. (2022). Suicide attempts among adults denying active suicidal ideation: An examination of the relationship between suicidal thought content and suicidal behavior. Journal of Clinical Psychology, 78(6), 1103–1117.
Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12(4), 189–201.
Williams, J. M. G., Mathews, A., & MacLeod, C. (1996). The emotional stroop task and psychopathology. Psychological Bulletin, 120(1), 3–24.
Williams, J. M., Watts, F. N., MacLeod, C., & Mathews, A. (1997). Cognitive Psychology and Emotional Disorders. John Wiley & Sons.
Wilson, K. M., Millner, A. J., Auerbach, R. P., Glenn, C. R., Kearns, J. C., Kirtley, O. J., ... & Cha, C. B. (2019). Investigating the psychometric properties of the Suicide Stroop Task. Psychological Assessment, 31(8), 1052.
Yaroslavsky, I., Allard, E. S., & Sanchez-Lopez, A. (2019). Can’t look away: Attention control deficits predict rumination, depression symptoms and depressive affect in daily life. Journal of Affective Disorders, 245, 1061–1069.
*Zheng, S., Zeng, W., Xin, Q., Ye, Y., Xue, X., Li, E., ... & Yin, H. (2022). Can cognition help predict suicide risk in patients with major depressive disorder? A machine learning study. BMC Psychiatry, 22(1), 1–13.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. However, Kate Clauss is supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Medical Research Service of the Veterans Affairs Portland Health Care System, and the Department of Veterans Affairs VISN 20 Northwest Mental Illness Research, Education, and Clinical Center (MIRECC). Maya O'Neil is supported in part by a Career Development Award from the VHA RR&D (1 IK2 RX002762-01A1) as well as the VA Health Services Research and Development (HSR&D) Center to Improve Veteran Involvement in Care (CIVIC). Amanda M. Raines is supported by the United States Department of Veterans Affairs (Clinical Science Research and Development Service) under Career Development Award-2 IK2cX001978-02. The contents of this article do not represent the views of the Department of Veterans Affairs of the United States Government.
Author information
Authors and Affiliations
Contributions
Kate Clauss conceptualized this paper, conducted the literature review, coded studies, conducted the analyses, and was involved in drafting the manuscript. Katherine Schafer coded studies, consulted on the analyses, and was involved in drafting the manuscript. Vanessa C. Somohano contributed to the updated literature search and coded studies. Maya O’Neil, as an expert in meta-analysis, consulted on the analyses and provided critical revisions. Joseph Constans, as a content expert in suicide and cognitive biases, provided critical revisions. Amanda M. Raines helped conceptualize the paper, develop the search terms, and provided critical revisions. Finally, Joseph R. Bardeen consulted on study coding and provided critical revisions.
Corresponding author
Ethics declarations
Conflict of Interest
Kate Clauss, Katherine Schafer, Vanessa C. Somohano, Maya E. O’Neil, Joseph Constans, Amanda M. Raines, and Joseph R. Bardeen declare that they have no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Clauss, K., Schafer, K., Somohano, V.C. et al. Attentional Risk Factors for Suicidal Thoughts and Behaviors: A Synthesis of the Literature and Meta-Analysis. J Psychopathol Behav Assess 45, 1141–1153 (2023). https://doi.org/10.1007/s10862-023-10077-1
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10862-023-10077-1