Imaging suicidal thoughts and behaviors: a comprehensive review of 2 decades of neuroimaging studies

Lianne Schmaal, Anne-Laura van Harmelen, Vasiliki Chatzi, Elizabeth T C Lippard, Yara J Toenders, Lynnette A Averill, Carolyn M Mazure, Hilary P Blumberg, Lianne Schmaal, Anne-Laura van Harmelen, Vasiliki Chatzi, Elizabeth T C Lippard, Yara J Toenders, Lynnette A Averill, Carolyn M Mazure, Hilary P Blumberg

Abstract

Identifying brain alterations that contribute to suicidal thoughts and behaviors (STBs) are important to develop more targeted and effective strategies to prevent suicide. In the last decade, and especially in the last 5 years, there has been exponential growth in the number of neuroimaging studies reporting structural and functional brain circuitry correlates of STBs. Within this narrative review, we conducted a comprehensive review of neuroimaging studies of STBs published to date and summarize the progress achieved on elucidating neurobiological substrates of STBs, with a focus on converging findings across studies. We review neuroimaging evidence across differing mental disorders for structural, functional, and molecular alterations in association with STBs, which converges particularly in regions of brain systems that subserve emotion and impulse regulation including the ventral prefrontal cortex (VPFC) and dorsal PFC (DPFC), insula and their mesial temporal, striatal and posterior connection sites, as well as in the connections between these brain areas. The reviewed literature suggests that impairments in medial and lateral VPFC regions and their connections may be important in the excessive negative and blunted positive internal states that can stimulate suicidal ideation, and that impairments in a DPFC and inferior frontal gyrus (IFG) system may be important in suicide attempt behaviors. A combination of VPFC and DPFC system disturbances may lead to very high risk circumstances in which suicidal ideation is converted to lethal actions via decreased top-down inhibition of behavior and/or maladaptive, inflexible decision-making and planning. The dorsal anterior cingulate cortex and insula may play important roles in switching between these VPFC and DPFC systems, which may contribute to the transition from suicide thoughts to behaviors. Future neuroimaging research of larger sample sizes, including global efforts, longitudinal designs, and careful consideration of developmental stages, and sex and gender, will facilitate more effectively targeted preventions and interventions to reduce loss of life to suicide.

Conflict of interest statement

HPB received an honorarium for a talk at Aetna. The other authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Number of neuroimaging studies on suicidal thoughts and behaviors published in the last 2 decades. The figure was based on the studies included in this review, calculated separately for studies only including adolescents and studies only including adults and divided into separate 4-year time bins for publication date
Fig. 2
Fig. 2
Overview of brain regions included in this review. These brain regions have been most reported in neuroimaging studies investigating structural, functional, and molecular brain alterations associated with suicidal thoughts and behaviors, with a subset of regions grouped more broadly into ventral prefrontal cortex, dorsal prefrontal cortex, insula, mesial temporal, subcortical, and posterior regions. DMPFC dorsomedial prefrontal cortex, dACC dorsal anterior cingulate cortex, RMPFC rostromedial prefrontal cortex, mOFC medial orbitofrontal cortex, vACC ventral anterior cingulate cortex, PCC posterior cingulate cortex, Thal thalamus, VS ventral striatum, Hippo hippocampus, Amyg amygdala, DLPFC dorsolateral prefrontal cortex, RLPFC rostrolateral prefrontal cortex, IFG inferior frontal gyrus, lOFC lateral orbitofrontal cortex, Put putamen, Caud caudate
Fig. 3
Fig. 3
A tentative brain circuitry model of suicidal thoughts and behaviors. Medial VPFC (ventral ACC, OFC, and RPFC), insula, amygdala, hippocampus, lateral temporal regions, posterior midline structures (posterior cingulate cortex and precuneus), dACC, ventral striatum, thalamus, and cerebellum contribute to the generation of suicidal ideation through their roles in excessive negative and blunted positive internal states, negative self-referencing, impairments in future thinking and rumination. DPFC (DLPFC and DMPFC), IFG, RPFC and dACC alterations further exacerbate suicidal thoughts and facilitate suicide behaviors due to their involvement in diminished cognitive control of thought, emotion, and behavior and impairments in cognitive flexibility and valuation of different decision options. Alterations in bottom-up and top-down connections between these extended medial VPFC and DPFC/IFG systems may contribute to the transition from suicidal thoughts to behaviors. The dACC and insula may mediate this transition. Dashed lines indicate speculative associations that need further confirmation by future structural and functional connectivity studies. DMPFC dorsomedial prefrontal cortex, dACC dorsal anterior cingulate cortex, RPFC rostral prefrontal cortex, OFC orbitofrontal cortex, vACC ventral anterior cingulate cortex, PCC posterior cingulate cortex, Thal thalamus, VS ventral striatum, Hippo hippocampus, Amyg amygdala, DLPFC dorsolateral prefrontal cortex, IFG inferior frontal gyrus, Put putamen, Caud caudate

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