Expansion and Reevaluation of the Implicit Association Test in Suicide Ideators and Suicide Attempters

Study Overview
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Brief Summary
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A new approach to investigate suicidal processes belongs to the broader neurocognitive picture and are so-called implicit associations. In dual process models of information processing a second functioning mode, the automatic processing mode, complements the conscious processing. Suicidal persons tend to have a stronger implicit association with death than non-suicidal persons. In this study, implicit associations between different unconscious cognitive constructs are compared among suicidal and non-suicidal patients. Therefore, an adapted version of the computer-based reaction time task (IAT-S) will be used. Four different versions of IATs are tested in this study. In the first version the implicit association between self / others and death / life is assessed (1). The second and third version measures the emotional evaluation of death (2) and life (3). In addition, in the fourth version the implicit association between death / life and internal / external locus of control is assessed (4). The implicit associations of these four IAT-S versions are compared between three groups: patients with suicidal behavior, patients with suicidal ideation, and a clinical group without previous suicide attempts and without suicidal ideation. The following hypotheses are made: in all four versions of the IAT-S, patients with previous suicidal behavior will have stronger implicit associations: between self and death as well as death and internal locus of control compared to all other groups. With a more positive evaluation of death and a more negative evaluation of life than all other participants.

Detailed Description
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In this study, four versions of the suicide-specific implicit association tests (IAT-S) are carried out. Previous studies have shown that suicidal persons have stronger associations between the constructs self and death. Furthermore, the strength of these implicit associations increases the risk of suicidal behavior in the follow-up period of six months by a factor of six. In these previous studies, the implicit self-death association (the so-called death-identity bias) was investigated. This study will additionally examine an implicit emotional evaluation (death-evaluation-bias). Therefore, two new versions of the IAT-S, which measure how death vs. life are emotionally evaluated, are being tested. In addition, a fourth version of the IAT-S was added and aims to clarify the implicit association between death / life and internal / external locus of control. Previous studies have shown that an internal locus of control is a protective factor and an external locus of control a risk factor for suicide attempts. In the present study, these four IAT-S versions are carried out with different groups of patients: patients with a suicide attempt (1), patients with suicide ideation (2) and patients with neither a suicide attempt nor suicide ideation (3). This cross sectional design allows us to test for group differences in regard to unconscious implicit associations. Hypothesis are described separately for each version of the IAT-S. Death association: patients in group 1 will have a higher implicit association between self and death than patients in group 2 and that patients in group 2 have a significantly higher implicit association between self and death than patients in group 3. Death evaluation: patients in group 1 will have more positive evaluations of death than patients in group 2 and patients in group 2 have a more positive evaluations of death than patients in group 3. Locus of control: patients in group 1 will have a stronger association between internal locus of control and death (a) and external locus of control and life (b) than patients in group 2, and that patients in group 2 have a significantly stronger association between internal locus of control and death (a) and external locus of control and life (b) than patients in group 3.

Official Title
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Expansion and Reevaluation of the Implicit Association Test in Suicide Ideators and Suicide Attempters

Conditions
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Suicide Attempt, Suicidal Ideation

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18-65 years Ability and willingness to participate in the study Ability to give consent Exclusion Criteria: Foreign language Diagnostic criteria: Psychoses, strong cognitive impairments (e.g. dementia)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Suicide Attempters (1)<br>patients with a suicide attempt | |
| Suicide Ideators (2)<br>patients with suicidal ideation | |
| Control Group (3)<br>patients without suicide attempt and without suicide ideation | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Implicit Association Test (IAT) | The German version of the Suicide Implicit Association Test (Rath et al., 2018) is administered using a computer paradigm and is designed to measure implicit associations with death using D-values. D is an individual effect size assessment that reflects the comparative difficulty of performing the two response conditions of the IAT, with a value of 0 indicating that the tasks had equivalent performance (Greenwald et al., 2003). D has a theoretical minimum of -2 and maximum of +2 when blocks of the same size are compared (Nosek & Sriram, 2007). The more positive the D-values, the stronger the association between the self and death than between the self and life. | One assessment at baseline after study information and informed consent was given | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Suicide Behaviors Questionnaire - Revised | The Suicide Behaviors Questionnaire measures suicidal behavior in the past and consists of four items. Item scores range from 3 to 18 with higher scores indicating more suicidal behavior (Osman et al., 2001). | One assessment at baseline after study information and informed consent was given | 
| Beck Scale for Suicide Ideation (BSS) | The Beck-Scale for Suicide Ideation measures suicidal thinking and consists of 21 items. Item scores range from 0 to 42 with higher scores indicating more suicidal ideation (Beck & Steer, 1993; Kliem & Brähler, 2016). | One assessment at baseline after study information and informed consent was given | 
| Beck Depression Inventory (BDI-II) | The Beck Depression Inventory measures the severity of depression and consists of 21 items. Item scores range from 0 to 63 with higher scores indicating a higher intensity of depression (Beck, Steer & Brown, 1996). | One assessment at baseline after study information and informed consent was given | 
| Mee-Bunney Psychological Pain Assessment Scale (MBPPAS) | The Mee-Bunney Psychological Pain Assessment Scale measures psychological pain and consists of 10 items. Item scores range from 10 to 50 with higher scores indicating more psychological pain (Mee et al., 2011). | One assessment at baseline after study information and informed consent was given | 
| Positive Mental Health Scale (PMH-scale) | Positive Mental Health Scale measures positive mental health ans consists of 9 items. Item scores range from 9 to 36 with higher scores indicating more positive mental health (Lukat, Margraf, Lutz, van der Veld & Becker, 2016). | One assessment at baseline after study information and informed consent was given | 
| Internal External Locus of Control-4 (IE-4) | The IE-4 is a Scale for the Assessment of Locus of Control and consists of two subscales with two items each. For each subscale, the mean value of the two items is calculated, which can range from 1 to 5 with higher scores indication more internal/external locus of control (Kemper, Beierlein, Kovaleva, & Rammstedt, 2012). | One assessment at baseline after study information and informed consent was given | 
| Mini-International Neuropsychiatric Interview (M.I.N.I.) | The Mini-International Neuropsychiatric Interview is a brief structured diagnostic interview to assess the most common psychiatric disorders (Sheehan et al., 1998). | One assessment at baseline after study information and informed consent was given | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Implicit Association Test