Understanding Suicide Risk in Adolescents: The Unique Role of Imagery

As the leading cause of death for adolescents worldwide, suicide is a critical public health concern. Researchers and clinicians alike are in need of accurate predictors of risk for suicidal behavior as well as evidence-based intervention strategies to reduce distress when risk is indicated. One particularly promising avenue for new gains in suicide research and treatment is examination of imagery. To date, suicidal ideation has nearly exclusively been assessed as verbal thoughts about suicide (e.g., I want to die) when suicidal imagery (e.g., imagining attempting suicide) may be a far more powerful predictor of suicidal behavior. In fact, the only studies to have examined suicidal imagery in adults found that the majority of adults report imagery when most suicidal and that increased suicidal imagery may be associated with heightened risk for suicide attempts. Imagery also may be effectively harnessed in treatment contexts to reduce suicide risk. Cognitive interventions for suicidal thoughts have largely been verbal in nature. Emerging research suggests, however, that imagery-based treatments are more effective than verbally-based interventions when directly compared. This may in part be because positive imagery has been shown to provide greater affective and physiological relief than positive verbal thought. The study proposed here will be the first to examine suicidal imagery in adolescents, evaluating whether suicidal imagery increases risk for suicidal events over 6 months post-discharge in a sample of psychiatrically hospitalized suicidal adolescents as well as whether response to positive imagery mitigates this risk. 
 
A total of 75 adolescents enrolled in my mentor's NIMH-funded longitudinal study of psychiatrically hospitalized suicidal adolescents will complete an additional assessment of suicidal imagery and a laboratory task that induces positive imagery about the future while affective and physiological data is collected. The aims of the study are as follows: 1) examine whether suicidal imagery predicts suicidal events and 2) evaluate whether amplified response to positive imagery protects against suicidal events. We hypothesize that suicidal imagery will prospectively predict suicidal events over and above suicidal verbal thoughts. We also expect that amplified affective and physiological response to positive imagery will protect against future suicidal events. This study has the potential to identify suicidal imagery as a new risk factor for suicidal behavior that could be assessed to improve clinical decision-making. This study also will inform clinical intervention development, determining whether it may be fruitful to intervene by increasing positive imagery about the future.