Factors that lead to suicidal thoughts and behaviors (STBs; i.e., passive or active suicidal ideation, behaviors, plans, or attempts) are complex. An important factor in suicide deaths and attempts is alcohol use; up to 36% of suicides involve acute alcohol use, while those with alcohol use disorder may account for up to 20-40% of suicides. Despite this relationship, processes that may be underlying the two are unclear. A common variable between alcohol use and STBs appears to be behavioral economic decision-making such as delay discounting (i.e., the devaluing of a commodity across time). This could be due to larger devaluation of rewards based on their delay for those with increased risk of suicide. However, other forms of discounting (i.e., probability; devaluing an outcome based on its likeliness, social; devaluing an outcome based on the interpersonal closeness of another person) have not been explored in their relation to STBs despite their potential theoretical relevance to suicide risk. Furthermore, losses of social reinforcers, particularly due to suicide or overdose death, could further result in worsened alcohol use and STBs. The contextualized reinforcer pathology model of addiction can be adapted to STBs and help to provide understanding of how alcohol use, reward valuation, and exposure to death can influence STBs and suicide risk. This model can also incorporate how treatment for alcohol use may also influence decision-making and STBs.
Our preliminary data from an alcohol treatment study and crowdsourced studies have found that recent STBs are related to increased discounting of delayed outcomes, higher alcohol use, and increased demand for alcohol. Exposure to suicide and overdose was also related to alcohol use and discounting of delayed outcomes. However, how alcohol use, decision-making, and STBs covary over time are not clear. Therefore, the purpose of this study is to determine how alcohol use, STBs, and behavioral economic decision-making covary over time. To test this, the proposed study will consist of a two-group randomized waitlist control trial for persons with risky alcohol use and active STBs (N = 50). Participants will be randomized to either immediate or delayed access to self-guided cognitive behavioral therapy modules for alcohol use. Participants will be expected to complete 7 full assessments one-month apart, along with 6 smaller assessments between full assessments to monitor alcohol use, STBs, and life events. This will allow for longitudinal analyses of how decision-making, alcohol use, and STBs covary over time, while also piloting the effectiveness of a standardized alcohol use treatment (Computer Based Training for Cognitive Behavioral Therapy; CBT4CBT) and how alcohol treatment might affect STBs.
