Acute Use of Alcohol and Attentional Bias Towards Suicide: An Experimental Test of the Attention-Allocation Model
Phase: NA
Conditions: Suicidal Ideas
Sponsor: University of Alabama at Birmingham

COVER PAGE​
 
Official Study Title: Acute Use of Alcohol and Attentional Bias Towards Suicide: An Experimental Test of the 
Attention-Allocation Model    
 
NCT number: NCT04276779 
 
Date of the document: October 28, 2020
 

Research Strategy 
Significance 
​
Acute use of alcohol (AUA) is associated with marked increased odds of suicide attempts6 and occurs 
prior to 34% of suicide deaths.16 Research has suggested a dose-response effect of AUA on odds of suicide 
attempts6 and deaths17 (see review15). Only one published study tested the proximal effects of AUA on suicidal 
ideation. Using timeline follow-back methodology with recently hospitalized individuals following a suicide 
attempt, AUA was associated with increases in next-hour suicidal ideation.18 In contrast, an unpublished daily 
diary study of college students with histories of alcohol use and suicidal thoughts demonstrated that AUA was 
negatively associated with suicidal ideation occurring that same day.11 These contradictory findings may be due 
to the presence, or lack thereof, of certain conditions on which alcohol-related suicidal thinking depends. For 
example, college students often socially drink or have positive alcohol expectancies, which may serve as 
competing cues that prevent alcohol use from facilitating suicidal thoughts.  
​
The conditions under which AUA confers risk for suicidal ideation and behavior are not well understood. 
This limited understanding raises questions about how to best target alcohol-related suicide risk for prevention 
and intervention efforts. Indeed, providers are unclear about the likelihood of suicidal behaviors among patients 
who use alcohol, and thus their treatment needs. For example, a recent study revealed that suicidal thoughts 
were insufficiently documented and one of the most incorrectly triaged problems among alcohol-intoxicated 
patients in emergency care settings19, highlighting the extent of missed intervention opportunities. 
Theory-guided studies will improve our understanding of the AUA-suicide connection by identifying targetable 
conditions and mechanisms. Although there are many theoretical articles about this connection, there are few, 
particularly experimental, tests of these theories. Identifying situational and individual factors upon which the 
impact of AUA on suicide may depend will inform our development of effective prevention strategies for 
alcohol-related suicide. 
 
Theoretical Framework 
​
Numerous researchers have proposed conceptual models of the impact of AUA on suicidal thoughts 
and behaviors.1-2, 10 A common thread throughout this work is an emphasis on the attention allocation model 
(AAM).7 The AAM is a promising model for clarifying the conditions under which AUA may affect suicide risk, 
and many studies have supported its use in explaining alcohol-facilitated interpersonal aggression.20 The AAM 
posits that alcohol intoxication creates a myopic effect on attention (i.e., attentional bias), such that it is 
allocated to the most salient stimuli. In the most comprehensive theory to date, Hufford (2001) applied the AAM 
to understanding the acute influence of alcohol use on suicide attempts and deaths.2 In brief, Hufford proposed 
that AUA plays a proximal role by facilitating suicide-related attentional bias and activating suicide-related 
expectancies. 
​
Attentional Bias towards Suicide-Related Cues. Attentional bias towards suicide-related cues 
(hereafter referred to as suicide-related attentional bias) is defined as the selective allocation of attentional 
resources toward suicide-related stimuli.3 AUA may increase risk for suicidal thoughts and behavior through its 
potential for facilitating suicide-related attentional bias. If painful emotional states are the most salient stimuli, 
intoxicated individuals’ cognitive resources will be allocated to these states and away from suicide-inhibiting 
stimuli, thereby increasing risk for suicidal ideation and behavior.1,2 Indeed, a meta-analysis has shown that 
suicide-related attentional bias is greater among people with histories of suicide attempts than those without.21 
A prospective study found that this bias predicted later suicide attempts better than other clinical predictors 
did.3 Thus, suicide-related attentional bias may be an important cognitive process occurring early in the suicidal 
trajectory, which AUA may facilitate under certain conditions. What is not known is whether AUA increases 
suicide-related attentional bias in the presence of salient cues, such as negative mood states.  
​
My past work guided by the AAM has revealed mixed support for this notion. Cross-sectional survey 
work showed that problematic drinking strengthened the association between depressive symptoms and 
suicidal ideation8, but an unpublished daily diary study of college students with histories of alcohol use and 
suicidal ideation failed to support an interaction between AUA and negative affect in predicting suicidal 
ideation.11 The latter finding may not generalize beyond college populations, as college students engage in 
frequent social drinking—providing competing cues that may protect against suicidal thoughts. Furthermore, 
these studies were limited by observational design and lack of measurement of suicide-related attentional 
bias—central to testing the AAM. An experiment examining suicide-related attentional bias would be the most 
rigorous test of this model, as potential third variables (e.g., depression history) and cue salience require 
careful control.  

Alcohol Expectancies. Likewise, there is limited understanding of individual differences, such as 
alcohol expectancies, that may further moderate these relations. As has been described in the other-directed 
aggression literature20, impelling and inhibiting factors may change the effect of AUA on suicide-related 
attentional bias and thus suicidal behavior. Alcohol expectancies, defined as one’s cognitions about the effects 
of alcohol intoxication22, may inhibit or impel suicidal thoughts and behaviors. First, AUA may facilitate suicidal 
behavior, in part, by activating suicide-related alcohol expectancies (i.e., increased pain tolerance and 
fearlessness).2 Thus, suicide-related alcohol expectancies may become a salient cue to which attention is 
directed, thus increasing suicide-related attentional bias. I could find no published studies that have examined 
suicide-related alcohol expectancies in relation to suicidal thoughts or behaviors. However, my prior work has 
shown that alcohol use is associated with perceived fearlessness and pain tolerance11,23—constructs theorized 
to enable someone to attempt suicide, if desired.24 Relatedly, my work has shown that problematic drinking is 
negatively associated with suicidal ideation among people with low aggressive expectancies.9 Other 
researchers have similarly shown that beliefs about alcohol reducing fear and pain were associated with 
increased risk for nonsuicidal self-injury.25 Alternative to this expectancy-activation hypothesis is the possibility 
that individuals drink alcohol purposefully to increase capability for an attempt. However, prior research has 
shown this is unlikely.26  
Other alcohol expectancies may also be relevant. Positive alcohol expectancies (e.g., mood 
enhancement, tension reduction) may impel or inhibit suicidal behavior, depending on one’s mood state. For 
example, individuals who are depressed may hold the belief that AUA will improve their mood; however, 
distress often increases when alcohol is consumed during negative mood states12,13, potentially increasing risk 
for suicidal thoughts and behavior.2 In contrast, individuals with such expectancies who experience positive 
mood prior to drinking are likely to experience increases in positive mood, and thus reduced likelihood of 
suicidal thoughts and behaviors. My preliminary work has partially supported this idea, showing that 
problematic drinking was negatively associated with suicidal ideation among those with high positive alcohol 
expectancies.9 Albeit limited, the literature suggests an interactive effect among AUA, mood, and alcohol 
expectancies on suicide risk but there remains a need to test the main effects of alcohol expectancies on 
suicide-related attentional bias. 
 
The Proposed Study 
​
This pilot experiment will examine the interactive impact 
of AUA, mood, and alcohol expectancies on suicide-related 
attentional bias (See Figure 1). This study is an innovative and 
robust exploration of theory-guided hypotheses. It will employ an 
experimental design (rare in the study of suicide-related 
constructs), 
alcohol 
administration, 
mood induction, and 
performance-based measure of suicide-related attentional bias. 
This study will 1) demonstrate feasibility of procedures, 2) 
explore sociodemographic differences in feasibility an of procedures and in suicide-related attentional bias, and 
explore conditional effects of AUA on suicide-related attentional bias by 3) mood states and 4) alcohol 
expectancies. 
​
 
Innovation 
​
Theorists have conjectured that the impact of AUA on suicide risk may depend on alcohol expectancies 
and increased suicide-related attentional bias. However, for obvious ethical reasons27, no experimental tests of 
this hypothesis exist. Addressing these challenges, the proposed experiment is an ethical and innovative test 
of these hypotheses; it examines a construct theorized to occur early in the trajectory towards suicidal behavior 
but which has not yet been examined in relation to AUA: suicide-related attentional bias.3 This experiment 
complements NIAAA’s strategic goals in basic science and prevention research, as it examines targetable 
cognitive factors that may influence suicidal ideation—a significant comorbidity among individuals with alcohol 
use disorders. This study challenges the current paradigm in alcohol-related suicide research in two important 
ways. First, it represents the first known experimental test of the AAM as it applies to suicide-related attentional 
bias and would guide methodology and parameters for future related studies, including those with samples 
higher in dysregulated mood. Further, this would be the first known study of suicide-related expectancies, 
another frequently hypothesized but untested correlate of alcohol-related suicide risk. If our hypotheses are 
supported, it would provide empirical support for a larger-scale test of the AAM as is relates to suicide risk. 
Future laboratory tests could test whether decreasing the salience of negative mood reduces suicide-related 

attentional bias. If alcohol expectancies are associated with suicide-related attentional bias, future work could 
test interactive effects of alcohol expectancies with mood and AUA on this bias. Downstream clinical 
implications include targeting expectancies and negative mood among individuals who consume alcohol. 
Ultimately, these findings may inform future basic and applied research examining the effects of AUA on 
suicidal ideation and behavior.  
 
Approach​
​
Consistent with theoretical and empirical work regarding the effects of AUA on suicidal thoughts and 
behaviors, this pilot study will test the interactive effects of 
AUA, 
negative 
mood, 
and 
alcohol 
expectancies 
on 
suicide-related attentional bias. The proposed study will employ 
a 2x2, between subjects design (alcohol-placebo X negative 
mood-positive mood, baseline levels of expectancies). See 
Figure 2 for a summary of our approach. ​
 
Preliminary Data  
​
Preliminary work has provided partial support of H1 
regarding feasibility of the study. We are conducting a partial 
test of our experiment (without alcohol administration) with a 
community sample examining the effects of the mood induction 
on mood and suicide-related attentional bias (Launched 
10/11/19; currently paused due to COVID19 safety concerns). 
Using similar recruitment procedures, 86 individuals have been 
screened; 55 met inclusion criteria; 41 attended a study 
session; 35 remained eligible after in-person screening; 1 
withdrew before completing the procedures. Thus, we had 
preliminary data from 34 participants. There was group 
equivalence in mood prior to mood induction (ps = .39-.81). 
T-tests revealed effectiveness of the mood induction. The 
negative mood group reported higher post-manipulation 
sadness (p=.001, Cohen’s d=1.24) and guilt (p=.001, d = 1.21) 
and lower joviality (p=.05, d = .68) compared to the positive mood group. These were medium to large effects 
despite 5 participants claiming the mood induction was ineffective in post-study interviews.  
​
Preliminary analyses showed that the distribution and variability in the suicide-related attentional bias 
scores (M=10.17, SD=41.32) were similar to that of prior studies28 of nonsuicidal subjects (M=3.96, SD=58.48, 
d=0.12). Preliminary analyses supported the anticipated direction of effect of mood on suicide-related 
attentional bias. The sample size for this analysis was reduced to 23 due to missing data on Stroop (software 
malfunction, n=2), mood induction and study aims deception failure (n=6), and exclusion of error trials 
(reducing analysis sample by 5). Although not statistically significant, the negative mood group showed more 
suicide-related attentional bias (M=15.77, SD=31.33) than the positive mood group (M=2.45, SD=48.24, 
d=.32). The negative mood group also had more depressive-related attentional bias (M=4.83, SD=58.48) than 
the positive mood group (M=-6.70, SD=41.96, d=.23). These data provide empirical support for the proposed 
study aiming to further test the feasibility of our procedures and hypotheses guided by the AAM. 
​
In support of H3, we found that alcohol use strengthens the association of depressive symptoms with 
suicidal ideation in cross-sectional, observational studies of clinical samples.8,29 In support of H4, we found that 
alcohol expectancies related to mood and disinhibition change the problem drinking-suicidal ideation relation.9 
In suicide decedents, we found that blood alcohol concentrations positively correlated with suicide means of 
rapid and high lethality, suggesting that AUA could be seen as reducing fear.30 Similarly, in my cross-sectional 
and daily diary work (F31), AUA positively correlated with fearlessness and perceived pain tolerance.11,23 
  
Study Participants 
​
A sample of 160 community adults (50% female; 10 pre-pilot; 150 pilot, about 38 per condition) will be 
recruited from the greater Birmingham area using flyers posted on the UAB campus and on Craiglist.com and 
Facebook.com (See Recruitment and Retention Strategy). Our original target pilot sample size was 120; 
however, we plan to oversample by 25% to account for the potential that 25% of participants may fail the mood 
induction. Participants will be told they are volunteering for a study testing “The Effects of Alcohol and Mood on 

Attention.” Documented in the Statistical Design and Power attachment, the sample size is a compromise 
between feasibility and precision of estimates, and provides reasonable confidence interval widths for effect 
estimates. Inclusion criteria: a) be between the ages of 21 and 65, b) have consumed an average of at least 
five or more (four or more for females) standard alcoholic drinks per occasion once over the past year, c) have 
self-administered a quantity of alcohol that is equal to or greater than the dose that will be administered in the 
lab on at least three occasions in the past year, and d) be able to read and write in English fluently. Exclusion 
criteria: a) active psychosis, suicidal ideation/intent, or mania; currently receiving psychiatric treatment; have 
received psychiatric treatment in past year or currently experiencing significant psychiatric distress, b) in 
treatment or recovery from drug or alcohol use disorders or abstaining from alcohol, c) any suicide attempt 
history, d) pregnant/breast-feeding or immediate plans to become pregnant, e) any chronic health problems or 
medications that would preclude the use of alcohol, f) (to minimize adverse reactions to alcohol or 
inappropriate alcohol dose) < 6 feet tall and over 230 lbs., or > 6 feet tall and over 250 lbs. or weighing 15% 
below one’s ideal body weight, g) (to minimize discomfort during lengthy study procedures) smoking more than 
15 cigarettes a day, h) orange allergies, i) color-blind or sight-impaired, and j) knowing someone who has 
participated in this study. Given this is the first study to test the effects of AUA on suicide-related attentional 
bias, our exclusion criteria are conservative to reduce adverse events related to increased distress. 
 
Procedures 
​
Screening and Session 1. See Table 1. Interested individuals will telephone the laboratory, and 
trained, supervised research assistants will assess inclusion and exclusion criteria via interview. Eligible 
participants will be scheduled for Session 1, which will last about one hour. Upon arrival, participants will 
provide informed consent, will be screened again for eligibility, and complete baseline measures. For screening 
purposes, participants will complete the Symptom Checklist-90-Revised (SCL-90-R; self-report measure of 
psychiatric symptomatology)31, the Paykel Suicide Scale32, and an adaptation of the telephone screening 
interview (to re-assess for exclusionary criteria). The Paykel Suicide Scale was selected given its ability to be 
modified for select periods and ease of comparison across study assessments. Participants who report a score 
of 65 or more on the SCL-90-R (i.e., indicative of significant psychiatric symptomatology) or current suicidal 
ideation will be excluded (and given appropriate referrals). Participants will also complete the Alcohol Use 
Disorders Identification Test (AUDIT33), which will be utilized to provide personalized alcohol use 
psychoeducation and treatment referrals. Per AUDIT recommendations and the ethical guidelines of alcohol 
administration research, all participants will receive literature focused on the reduction of hazardous drinking at 
the end of the study. 
Upon completion of this initial screening battery, participants will then complete a separate computer 
assessment battery, including measures of demographics and suicide and alcohol-related constructs (however, 
these will be kept to a minimum to mask study aims). Relevant to the current study aims, a measure of alcohol 
expectancies (Comprehensive Alcohol Expectancy Questionnaire [CAEQ]34-35) will be included. The CAEQ is a 
reliable and valid measure of alcohol expectancies, with confirmatory analysis supporting it in 
alcohol-dependent and college student samples.36 The following CAEQ subscales will be used for the 
purposes of this investigation: Social Assertiveness/Positive Affect and Tension Reduction. We will also include 
items we developed regarding suicide-related alcohol expectancies (SRAEs), as there is no validated measure 
of suicide-related expectancies. These items will be dispersed throughout the CAEQ to keep subjects naïve to 
study aims. Our preliminary work supported the reliability and validity of the SRAE measure in a sample of 80 
college students. The measure had high internal consistency (α=.96). Scores were normally distributed 
(Range=93; M=53.83, SD=23.70; Skewness=-0.11, Kurtosis=-0.91). Concurrent validity was supported. 
Hazardous drinkers reported greater SRAEs than non-hazardous drinkers (M=61.00, SD=16.39 vs. M=49.55, 
SD=26.27, d=0.52), and SRAEs were positively correlated with past year suicidal ideation (r=.43, p<.01). 
Finally, a measure of attentional abilities (Conners' Adult ADHD Rating Scales, Self Report: Long Version; 
[CAARS-LV]37) will be included to reinforce the deception that the study is investigating broad attention. 
Participants will be compensated via cash gift card ($20 for this session). 
Session 2. Participants who remain eligible will be scheduled for a second appointment, which will be 
one to ten hours in duration, depending on their randomly-assigned condition (i.e., alcohol vs. placebo). When 
scheduling Session 2, participants will be told to refrain from drinking alcohol or using recreational drugs 24 
hours prior to the session and to refrain from eating four hours prior to the session. Upon arrival at the 
laboratory, eligibility will be confirmed, including a breathalyzer test to ensure a zero BrAC and field sobriety 
test for comparison post-detoxification. Those with nonzero BrAC will be rescheduled. Female participants will 
be given a pregnancy test kit and asked to produce a urine sample in a private bathroom located adjacent to 

the laboratory (those with positive tests will be excluded). Height and weight will be measured to calculate 
alcohol dosage. We will assess pre-manipulation mood via the Positive and Negative Affect 
Schedule-Expanded Form (PANAS-X)–sadness, guilt, and joviality subscales38 and 2-item Brief Hopelessness 
Measure.39 
Manipulation of AUA and Mood: We will randomly assign eligible participants to conditions using a 
randomization scheme. They will proceed first to beverage administration. We will tell all participants that they 
are drinking alcohol. Participants in the placebo control group will receive beverages containing 4 mls of 
alcohol in juice and 4 mls layered on top of the juice. In addition, the rims of the glasses will be sprayed with 
alcohol just prior to being served. Participants in the alcohol condition will be administered two drinks 
consisting of an overall dose of 0.99 g/kg (males) or .90 g/kg (females) body weight of 95% ethanol USP mixed 
in a 1:5 ratio with Tropicana orange juice. Standard drink equivalents will be based on body weight. The 
beverage will be poured into two glasses in equal quantities. This dose has been used in past studies of 
alcohol-related self-aggression and reliably produced BrAC levels between .08%-.10%, which is within NIAAA 
safety guidelines.40 This dose has consistently potentiated self-aggressive behavior5 and thus was chosen to 
maximize the likelihood of producing an alcohol-related effect on suicide-related attentional bias. We will serve 
all beverages chilled with no ice. We will allot twenty minutes for beverage consumption. Participants will be 
given their two glasses at equally-spaced times to control drinking rate. Immediately after consumption, all 
participants will rinse their mouths with water. We will assess BrACs of all participants with an Alco-Sensor IV 
breath analyzer every five minutes for 20 minutes for placebo participants and until .08% on the ascending limb 
of the BrAC curve for alcohol participants. ​
​
Upon reaching a BrAC of at least .075%, a brief manipulation check will be performed. Participants will 
rate their level of intoxication on a scale of 0 (0=not at all) to 11 (11=more drunk than I have ever been).41 
Immediately after, participants will be randomized to a 10-minute mood induction procedure. A self-referent 
plus musical mood induction paradigm will be employed to induce a positive or negative mood state in 
participants.42 Self-referent statements (e.g., negative or positive self-statements) and musical mood inductions 
are both valid, stand-alone procedures for inducing mood. The combination of both has been shown to be 
effective in inducing a temporary negative mood state in 75% of subjects.42 The combined negative mood 
induction paradigm was created based on a modernized version43 of a seminal, self-referent mood induction44 
and a musical mood induction.45 Participants will read 25 statements presented in a timed, PowerPoint 
slideshow, first to themselves and then aloud, and are instructed to “feel and experience each statement as it 
would apply to you personally.” They will concentrate on each statement for 20 seconds and then proceed to 
the next one. Five statements were revised to generalize to the greater population. This is done simultaneously 
with the musical negative mood induction paradigm, which involves listening to a piece of music that conveys a 
particular mood (negative: Prokofiev’s ‘Russia Under the Mongolian Yoke’ at half speed; positive: Delibes 
‘Coppelia’). These musical pieces were chosen as they are the most studied of the effective musical induction 
procedures.46 Subjects will be left alone in the room during the mood induction to lessen inhibitions but will be 
observed by way of a window. 
Manipulation Check and Dependent Variable Measurement: After the mood induction, participants 
will complete the PANAS-X subscales as a manipulation check (<2 min). Participants will then complete a 
Stroop47 task modified to assess attention towards suicide-related cues (i.e., Suicide Stroop3). This modified 
Stroop task is a performance-based measure conducted via computer that documents response latencies on 
identification of the colors of words presented on the screen. Neutral (museum, paper, engine), negative 
(alone, rejected, stupid), positive (happy, success, pleasure), and suicide-related (suicide, dead, funeral) 
categories of words are presented, and greater response latencies indicate greater interference of the 
semantic content in naming the color. Participants will be instructed to indicate the word color as quickly and 
accurately as possible using red and blue keys. Stimuli will be presented using Empirisoft DirectRT software.48 
Trials will be presented in a random order to each participant. Interference for suicide-related words (i.e., 
suicide-related attentional bias) will be calculated by subtracting the response latencies for neutral words from 
the latencies for suicide-related words.3 Internal consistency coefficients for reaction time tasks like Stroop 
tasks are typically low49-50, and it has been suggested that using internal consistencies from past studies is 
inadvisable as sample characteristics can have a significant impact on the internal consistency.49 Nonetheless, 
in our partial test, the internal consistencies for the interference scores (using a split-half coefficient) and the 
suicide trial reaction times were .49 and .86, respectively, which are typical of Stroop tasks50-51 and much better 
than reliabilities in prior studies using the Suicide Stroop.28 The Suicide Stroop has demonstrated construct 
validity through associations with past and future suicidal behavior.3,21 Thus, It serves as the primary outcome 

of interest. Following the Stroop, participants will complete the 2-item Brief Hopelessness Measure39 (a 
secondary outcome, see Potential Problems below). 
Post-Study Interview and Debriefing: Following dependent variable measurement, BrAC readings 
will be obtained for individuals in the alcohol condition. Participants will be allowed to use the restroom and 
encouraged to drink the provided water. While detoxifying, individuals will be given access to magazines, 
access to WiFi/a tablet with internet, and offered snacks, water, and a full meal. Intoxicated participants will be 
debriefed after a BrAC reading of .03% (sober participants will be interviewed and debriefed in full 
immediately). Given that study procedures assess suicide-related constructs and, for some participants, a 
negative mood induction and alcohol administration, a Post-Debriefing Safety Interview will be administered 
prior to participants leaving the laboratory. This evaluates deception failures, participants’ experiences of 
distress due to study participation, and suicide risk. Although changes in overt suicidal ideation are not 
expected, participants will complete the Paykel Suicidal Ideation Scale again to screen for current suicidal 
ideation (and indicate if additional risk assessment is needed). The debriefing will include a description of the 
study aims, hypotheses, revealing of deception (regarding true study aims, placebo), and safety checks. 
Research staff will go over the AUDIT fact sheets with all participants and answer any questions. If they require 
or request referrals, research staff will discuss the reason for the referrals (e.g., problematic drinking). 
Participants will be paid and thanked for their participation. Participants will be compensated via cash gift card 
($20 per hour, up to $200 for 10 hours). Intoxicated participants will not be allowed to leave until their BrAC has 
fallen to 0.03% on two consecutive readings (per NIAAA guidelines; See Protection of Human Subjects 
attachment). All participants will leave via paid cab. 
 
Analytic plan 
H1: We will quantify the number of individuals screened and the percentage who are eligible and 
participate. We will run descriptive statistics to quantify 1) prevalence of successful mood induction, 2) distress 
ratings post-study session, and 3) number of adverse events. Using measures of effect size, t-tests, and Chi 
square analyses, we will examine sociodemographic differences in these feasibility factors. H2: We will use 
measures of effect size, t-tests, and Chi Square analyses to examine sociodemographic differences in 
suicide-related attentional bias scores. H3: The interactive effect of mood and AUA on suicide-related 
attentional 
bias 
will 
be 
estimated 
using 
a 
general 
linear 
model 
of 
the 
form 
 H4: The interactive effect of alcohol expectancies and AUA 
𝑌
^ = β0 + β1𝐴𝑙𝑐𝑜ℎ𝑜𝑙+ β2𝑀𝑜𝑜𝑑+ β3𝐴𝑙𝑐𝑜ℎ𝑜𝑙×𝑀𝑜𝑜𝑑.
on suicide-related attentional bias will be estimated using a general linear model of the form 
 For H3 and H4, we will use linear contrasts 
𝑌
^ = β0 + β1𝐴𝑙𝑐𝑜ℎ𝑜𝑙+ β2𝐸𝑥𝑝𝑒𝑐𝑡𝑎𝑛𝑐𝑖𝑒𝑠+ β3𝐴𝑙𝑐𝑜ℎ𝑜𝑙×𝐸𝑥𝑝𝑒𝑐𝑡𝑎𝑛𝑐𝑖𝑒𝑠.
to estimate effects. Inferences will be conducted using 68% CIs for comparisons of interest, as significance 
testing is not a primary study aim. See Statistical Design and Power attachment. 
 
Table 1. Summary of Research Tasks and Measures  
Telephone Screening  
Session 1  
Informed Consent and Eligibility Screening  
Primary Baseline Assessments 
Alcohol Use Disorders Identification Test 
Paykel Suicide Scale (lifetime) 
Comprehensive Alcohol Expectancy Questionnaire (CAEQ); Suicide-Related Alcohol Expectancies 
Secondary baseline questionnaires related to alcohol, psychiatric, and mood37, 52-54 
Session 2  
Eligibility confirmation (Paykel Suicide Scale [current]; Changes in medication/health status) 
Random Assignment 
Pre-Manipulation Mood and Cognition (PANAS-X; Brief Hopelessness Measure) 
Manipulation Procedures and Checks 
Alcohol or placebo administration; Post drinking BrAC measurement; Manipulation check 
Mood induction (positive or negative); Manipulation check: PANAS-X 
Outcome Measure: Modified Stroop-Suicide (primary outcome of interest), Brief Hopelessness Measure  
Post-Study Procedures: Detoxification (if applicable); Post-Study Verbal Interview, Paykel Suicide Scale 
(current; risk screening for post study interview), Debriefing, Payment 
Follow-up Wellness Check Phone Calls (day of, day following, and week following) 

Potential Problems, Alternative Strategies, Benchmarks for Success, and Impact 
​
Given this is the first known project to examine the effects of AUA, mood, and expectancies on 
suicide-related attentional bias, our ongoing partial test of the proposed study includes another suicidal bias 
measure: the Implicit Associations Task-Life/Death (IAT-SI4), which measures implicit suicidal cognition. Scores 
indicate level of identification with life versus death and correlates with suicidal behavior.4 We will replace the 
Stroop with this task if our partial test of the reveals that the mood induction influences IAT-SI scores but not 
Stroop scores. Even if our proposed pilot study does not find effects of AUA, mood, and expectancies on 
suicide-related attentional bias, we have a post-manipulation measurement of hopelessness—a strong risk 
factor for suicide. This secondary dependent variable could serve as the basis for an R01. If in our 10 pre-pilot 
subjects, the mood induction fails >50% of the time, we will use another effective mood induction (i.e., 
imaginative film). Further, we are oversampling by 25% (150 subjects instead of 120, in case of 25% mood 
induction failures). Finally, although our proposed sample may not generalize to suicidal individuals, we believe 
any effect found in the present study will be larger in a sample of suicidal individuals. This study’s strong 
internal validity offers a strong basis for future studies of individuals with higher levels of distress. Impact. If 
hypotheses are supported, it would provide strong support for the AAM as it applies to suicide risk. Future 
studies could test whether decreasing the salience of negative mood or suicide-related expectancies reduces 
suicide-related attentional bias and thus suicide risk. Possible downstream implications include the potential to 
inform future basic and applied research examining the effects of AUA on suicide risk. Finally, this project will 
provide me with the relevant experience to conduct future experiments using alcohol administration to 
investigate behavioral and affective consequences of AUA.