Acta Psychiatr Scand 2005: 112: 294–301 Copyright
2005 Blackwell Munksgaard

All rights reserved ACTA PSYCHIATRICA

DOI: 10.1111/j.1600-0447.2005.00585.x
SCANDINAVICA

Executive functioning in depressed patients

with suicidal ideation
Marzuk PM, Hartwell N, Leon AC, Portera L. Executive functioning in P. M. Marzuk, N. Hartwell,
depressed patients with suicidal ideation. A. C. Leon, L. Portera
Acta Psychiatr Scand 2005: 112: 294–301.
2005 Blackwell Munksgaard. Department of Psychiatry, Weill Medical College,
Cornell University, New York, NY, USA
Objective: Suicidal thinking has been associated with cognitive
rigidity, however, not all depressed patients contemplate suicide.
Therefore, we hypothesized that compared with depressed subjects
without suicidal ideation, depressed individuals with suicidal ideation
would display poorer performance on measures of executive
functioning that involve mental flexibility.
Method: In-patients with a current major depressive episode who had
no current suicidal ideation (n ¼ 28) were compared with those who
had current suicidal ideation (n ¼ 25) on measures of executive Key words: cognition disorders; depression;
functioning and two neurocognitive tests that predominantly assess neuropsychological tests; frontal lobe; suicide
non-frontal regions. Peter M. Marzuk MD, Office of Curriculum and
Results: Compared with non-suicidal depressed patients, depressed Educational Development, Weill Medical College,
suicidal patients performed significantly worse on several measures of Cornell University, 1300 York Avenue, Box 243,
executive functioning after controlling for age, IQ, severity of New York, NY 10021, USA.
depression and prior suicide attempts. The two groups performed E-mail: pmmarzuk@med.cornell.edu
Presented in part at the 29th Annual Meeting of the
similarly on tests that predominantly assess non-frontal regions.
International Neuropsychological Society, Chicago, IL,
Conclusion: Depressed individuals contemplating suicide have February 14–17, 2001.
cognitive rigidity, which does not appear to be a global brain
dysfunction. Suicidal mental states may result from dysfunctional
executive decision-making that is associated with the frontal lobe. Accepted for publication May 26, 2005

Significant outcomes
• Compared with non-suicidal depressed patients, suicidal depressed patients performed significantly
worse on several measures of executive functioning after controlling for age, IQ, severity of
depression and history of prior attempts.
• The pattern of test results suggests a mental inflexibility associated with frontal lobe dysfunction may
underlie suicidal thinking and the Ôexecutive decisionÕ to commit suicide.
• Because both those depressed subjects with suicidal ideation and without suicidal ideation performed
similarly on neurocognitive tests that predominantly assess non-frontal brain regions, the cognitive
rigidity of suicidal ideation does not appear to be part of a global brain dysfunction.

Limitations
• Depressed individuals were not studied medication-free; however, the suicidal and non-suicidal
groups did not differ on the types of medications they were taking at the time of testing.
• Personality traits, which might correlate with some neuropsychological measures, were not assessed.
• The person who administered the neurocognitive tests was not blind to the subjectsÕ suicidal status.

294
 Executive functioning, depression, and suicidal ideation
Introduction
Persons in suicidal mental states are often consid-
ered to have cognitive rigidity, a broad term that
includes dichotomous (all-or-none) thinking, and
problem solving deficits (1–5). Individuals with all-
or-none thinking conceptualize their problems in
absolute dichotomies such as Ôgood or badÕ, Ôright
or wrongÕ, Ônow or neverÕ, etc. Rigid adherence to
dichotomies can lead to lethal situations in which a
depressed, suicidal person sees his coping options
in the all-or-none terms of a miserable life vs.
death, with few, if any, intermediate possibilities
between these stark choices. The cognitive rigidity
of suicidal thinkers may also contribute to problem
solving deficits (6–12). That is, when cognitively
rigid and depressed individuals are overwhelmed
by stresses, they become incapable of generating
alternative solutions necessary for adaptive coping
and become increasingly hopeless. High levels of
hopelessness then place these individuals at greater
risk for suicide.
The thought of ultimately committing suicide is,
in effect, an Ôexecutive decisionÕ likely made, in
part, in the prefrontal areas of the brain. These
brain regions involve the weighing of changing
alternatives and generating of new ones, the ability
to strategize out of Ôcorners, traps or dead endsÕ,
and the initiation and execution of plans – all
functions that are hampered by cognitive rigidity.
Depression, the most common syndrome associ-
ated with suicidal thinking, and the most common
clinical syndrome associated with completed sui-
cide, is known to involve cognitive dysfunction,
particularly on ÔexecutiveÕ tasks (13–18). In addi-
tion, evidence from postmortem and neuroimaging
studies suggest depression involves alterations in
the structure, metabolism or receptor binding of
the prefrontal cortex, especially the left dorsolat-
eral prefrontal region (19–22). However, most
depressed patients do not commit suicide, and
many have never been suicidal ideators. Thus it is
important to identify the specific factors that
increase the risk of suicide in depressed individuals.
Several studies (8, 23) including a recent, well
controlled one by Keilp et al. (24), have found that
depressed patients with a history of suicide attempts
have more cognitive rigidity as evidenced by dimin-
ished performance in executive functioning com-
pared with depressed patients without a history of
suicide attempts. Suicidal thinking is much more
common than suicidal behavior, but it is not known
if the same relative decrease in executive perform-
ance would be found in depressed suicidal ideators
compared with depressed non-ideators. As cognitive
rigidity is mainly a disturbance in thinking, we
hypothesized that compared with non-suicidal
depressed patients, depressed patients who had
suicidal ideation would also display poorer per-
formance on tests of executive functioning, partic-
ularly tasks that require cognitive flexibility. To
discount the possibility that poorer performance in
the suicidal ideation group is merely part of a diffuse
global brain dysfunction, we also administered two
tests that tap into functions that are primarily based
in non-frontal regions. We hypothesized there
would be no difference between the two groups on
these measures.
Aims of the study
The aim of the study was to determine whether,
compared with depressed, non-suicidal individuals,
depressed individuals with suicidal ideation display
decreased cognitive flexibility as measured by
neuropsychological tests of executive functioning.
Material and methods
Subjects
All subjects were recruited from the in-patient unit
of the Payne Whitney Psychiatric Clinic of the New
York Presbyterian Hospital, a 64-bed unit of a
private, university hospital. To be included in the
study, subjects had to meet criteria for a current
major depressive episode (unipolar or bipolar) on
the basis of the Structured Clinical Interview for
DSM-IV (25), which was administered by a doc-
toral candidate in psychology (N.H.). In addition,
subjects were required to be over 18 years of age,
primarily English speaking and capable of under-
going structured clinical interviews and neuropsy-
chological testing. Individuals were excluded from
study if they had mental retardation, dementia,
alcohol or substance abuse within the past
6 months, or a history of anoxic or traumatic
brain damage, cerebrovascular accidents, transient
ischemic attacks or loss of consciousness that
exceeded 1 h.
As the study involved seriously depressed and
suicidal in-patients, it was not possible to withhold
psychotropic medications prior to testing. However,
we excluded patients who were currently taking
lithium, conventional antipsychotics, tertiary amine
tricyclic antidepressants such as imipramine or
amitriptyline, or medications known to affect neu-
rocognitive functioning (26). In addition, we exclu-
ded individuals who had received electroconvulsive
treatment in the past year. To assess the possibility
of impaired performance caused by the sedating
effects of psychotropic medications, we also exclu-
295
Marzuk et al.
ded subjects who were not able to repeat at least a
five-digit sequence forward on the Wechsler Adult
Intelligence Scale-Revised (WAIS-R) (27) Digit
Span Subtest. The study was approved by the
institutional review board of the Weill Medical
College of Cornell University. After a complete
description of the study to the subjects, we obtained
their written informed consent.
Measures of suicidal ideation
All subjects received the Scale for Suicidal Ideation
(SSI), which is a 19-item clinician-administered
scale that assesses current levels of suicidal ideation
(28). It has high internal consistency (coefficient
alpha ¼ 0.90 in this sample) as well as satisfactory
levels of concurrent, discriminate, and constructive
validity. A maximum score of 38 may be obtained,
indicating extreme levels of suicidality. Items 4 and
5 pertain to current suicidal thoughts of an active
or passive nature. They also serve as gate items,
with a positive response on either one leading to
inquiry into the remaining 14 items regarding
details about current suicidal thoughts. The meas-
ure yields both categorical (yes or no – either item 4
or 5 > 0) and continuous (total score on all 19
items) variables, which were used in subsequent
statistical analyses. Individuals who scored >0 on
either item 4 or 5 were considered to be currently
suicidal. Individuals who received a score of 0 for
both these items were considered to be currently
non-suicidal. The suicidal status (i.e. current suici-
dal ideation vs. no current suicidal ideation) was
assessed with the SSI immediately prior to the
administration of the neuropsychological battery.
In addition, subjects were asked about the number,
dates and circumstances of prior suicide attempts.
Neurocognitive and psychopathologic assessments
Immediately prior to neuropsychological assess-
ment, all subjects were administered standard rating
scales to assess severity of depression, anxiety, and
hopelessness, and impulsivity. These scales included
the Hamilton Rating Scaling for Depression
(HRSD) (29), 24 items; the Hamilton Anxiety
Scale HAS) (30), the Beck Hopelessness Scale
(31), and the Barratt Impulsiveness Scale (BIS)
(32). To obtain an estimate of verbal intelligence
(VIQ), which correlates with performance on many
executive measures, subjects received the American
New Adult Reading Test (AMNART) (33). Sub-
jects underwent a neuropsychological battery that
consisted of standardized measures of executive
functioning, including mental flexibility, problem
solving, ability to generate multiple solutions to
296
situations, strategic planning, and set shifting.
These included the Wisconsin Card Sorting Test
(WCST) (34, 35); the Mazes subtest of the Wechsler
Intelligence Scale for Children, Third Edition
(WISC-III) (36); two measures of verbal and figural
fluency, the Controlled Oral Word Association Test
(COWAT) (37, 38) and the Five Point Test (FPT)
(39) respectively; the Stroop Color Word Test
(SCWT) (40); and the Trail Making Test, Parts A
and B (41). For the latter we used difference score
(trails B minus A), which removes the psychomotor
element from the test and yields a purer measure of
set shifting.
To ensure that poorer performance in executive
tasks in suicidal subjects was not part of a more
diffuse cognitive impairment, subjects were admin-
istered two tasks that are not considered primary
measures of executive functioning. These included
the Boston Naming Test (BNT) (42), a confronta-
tion naming task that requires the subject to
identify a series of 60 pictured objects and the
Rey Osterieth Complex Figure Test (43) – Copy
Condition that requires a subject to copy a
complex geometric figure.
All subjects received the neuropsychological bat-
tery within 7 days of admission to the psychiatric
unit. Subjects were assessed between 10 a.m. and
3 p.m. to minimize possible effects of diurnal vari-
ation in depressive symptoms. To account for
possible effects of fatigue related to the order of
test presentation, subjects were randomly assigned
by computer-generated random numbers to receive
the tests in one of two possible sequences: i) WAIS-R
Digit Span, AMNART, Trail Making Test (parts A
and B), COWAT, FPT, SCWT, Rey Copy WCST,
WISC-III Mazes and BNT or ii) WAIS-R Digit
Span, WCST, WISC-III Mazes, Rey Copy BNT,
AMNART, Trail Making Test (parts A and B),
COWAT, FPT, and SCWT. All neuropsychological
assessments were administered by a single examiner
(N.H.) who had had extensive prior experience in the
administration of neurocognitive tests.
Statistical analyses
The demographic and clinical characteristics of
suicidal and non-suicidal subjects were compared
using t-tests for continuous variables and chi-
squared tests for categorical variables. The neuro-
psychological performance of the suicidal and non-
suicidal subjects was compared using a multiple
linear regression approach to analysis of covariance
(ANCOVA). Age and VIQ skills are known to be
related to many cognitive test scores. In addition,
depression is associated with cognitive effects such
as decreased attention, concentration, psychomotor
 Executive functioning, depression, and suicidal ideation

speed, and memory. Thus, the separate regression
models for each neuropsychological variable inclu-
ded two successive blocks of variables: i) age, VIQ,
severity of depression, history of prior suicide
attempts, and ii) suicide status (i.e. current ideation
vs. no ideation). The hypothesized differences in
neuropsychological performance between the suici-
dal and non-suicidal groups were evaluated with an
F-test of the significance of the incremental propor-
tion of variance (R2 change) accounted for by suicide
status, over and above that accounted for by age,
VIQ, severity of depression and history of prior
suicide attempts. The two-tailed alpha level for each
test was set at 0.05.
Results
Characteristics of the study groups
The study group (n ¼ 53), as a whole, was com-
posed of persons with an average age of 40 years
(60% women, 60% Caucasians), with nearly half
of them having at least some college education, and
average VIQ. There were no significant differences
on these demographic characteristics between the
suicidal and non-suicidal groups with the minor
exception of age (Table 1).
Most of the study group (approximately 85%)
had a current major depression (unipolar). Nine-
teen percent also had dysthymia. The suicidal and
non-suicidal groups did not differ in type of
depression (major depression vs. bipolar) nor in
mean age of onset of depression (early 20s),
number of previous depressive episodes (approxi-
mately 6–7), length of current episode (10–
12 weeks) or proportion with a previous suicide
attempt (about 50%) (Table 1). In the group with
current suicidal ideation, seven of 25 (28%) had
made a recent suicide attempt (attempt within
1 month of admission) compared with five of 28
(18%) in the group with no current suicidal
ideation (v2 ¼ 2.27, d.f. ¼ 2, P ¼ 0.32).

Table 1. Demographic and clinical characteristics of the study groups

Statistics
Current suicidal No current suicidal
Characteristics ideation (n ¼ 25) ideation (n ¼ 28) Test d.f. P-value

Demographics
Age, years – mean (SD) 36.0 (11.9) 42.3 (11.2) t ¼ 1.97 51 0.05
Female (%) 56.0 64.3 v2 ¼ 0.11 1 0.74
White (%) 56.0 67.9 v2 ¼ 3.89 3 0.27
Education £12 years (%) 64.0 42.9 v2 ¼ 2.55 2 0.28
Estimated verbal IQ – mean (SD)* 106.3 (7.2) 108.9 (8.5) t ¼ 1.18 51 0.25
Right-handed (%)  96.0 92.9 v2 ¼ 0.24 1 0.62
Diagnosesà(%)
Major depression 84.0 89.3 v2 ¼ 0.03 1 0.87
Bipolar disorder depressed 16.0 10.7 v2 ¼ 0.03 1 0.87
Dysthymia 16.0 21.4 v2 ¼ 0.02 1 0.88
Illness characteristics, mean (SD)
Age of onset of first MDE, (years) 22.8 (13.5) 23.5 (12.9) t ¼ 0.18 51 0.86
No. of depressive episodes 6.0 (4.3) 6.9 (3.6) t ¼ 0.86 51 0.39
Length of current episode, (weeks) 13.9 (22.1) 11.0 (13.5) t ¼ )0.57 51 0.57
Previous suicide attempt (%) 60.0 39.2 v2 ¼ 2.27 2 0.32
Psychopathologic Measures, mean (SD)
HRSD 22.4 € 3.8 21.7 € 6.0 t ¼ )0.52 51 0.61
HAS 10.2 € 2.8 10.1 € 2.8 t ¼ )0.13 51 0.90
BHS 11.8 € 4.6 8.1 € 5.6 t ¼ )2.61 51 0.01
BIS 52.1 € 18.8 48.3 € 18.0 t ¼ )0.74 51 0.46
Current medications
SSRI antidepressants§ 44.0 67.9 v2 ¼ 2.17 1 0.14
Benzodiazepines– 24.0 46.4 v2 ¼ 2.00 1 0.16
Antipsychotics** 16.0 21.4 v2 ¼ 0.02 1 0.88
Mood stabilizers   12.0 17.9 v2 ¼ 0.04 1 0.83

MDE, major depressive episode; HRSD, Hamilton Rating Scale for Depression (24-item version with suicide item removed from total score); HAS, Hamilton Anxiety Scale; BHS,
Beck Hopelessness Scale; BIS, Barratt Impulsiveness Scale.
*Assessed by American New Adult Reading Test.
 Assessed by direct observation.
àTotal may exceed 100% as those with major depression or bipolar disorder, depressed may also have dysthymia.
§Includes fluoxetine, paroxetine, and also venlafaxine.
–Includes alprazolam, diazepam, flurazepam, lorazepam, midozolam, oxazepam, quazepam, temazepam, triazolam.
**Includes risperidone, olanzapine.
  Includes divalproex sodium, valproic acid, carbamazepine.

297
Marzuk et al.

At the time of neuropsychological testing, both
groups were moderately depressed (mean HRSD
score <23) and had comparable levels of anxiety
and impulsivity. However, not unexpectedly, the
group with current suicidal ideation was signifi-
cantly more hopeless (Table 1).
Approximately one-half of the study group were
taking selective serotonin reuptake inhibitors
(SSRI) antidepressants; one-third were taking
benzodiazepines, one-fifth were taking either ris-
peridone or olanzapine, and one-seventh were
taking a mood stabilizer. However, there were no
differences between the suicidal and non-suicidal
groups in the proportion of patients taking a
particular class of medication (Table 1).
Neuropsychological performance
In ANCOVAs that controlled for age, VIQ and
severity of depression, compared with non-suicidal
depressed persons, the depressed persons with
suicidal ideation showed significantly worse per-
formance on several measures of executive func-
tioning including the WCST (number of
perseverative errors), trails B minus A, and the
WISC-III mazes (Table 2). There were no group
differences on verbal or figural fluency or the
Stroop Interference Task. As hypothesized, there
were no differences between suicidal and non-
suicidal groups in performance on measures that
primarily assess non-frontal regions, i.e. the BNT
and the Rey Copy Task.
Discussion
In this study we found that compared with
depressed non-suicidal patients, patients who
were depressed and had current suicidal ideation
displayed poorer performance on several measures
of executive functioning after controlling for age,
estimated VIQ, and severity of depression. In these
variables, a substantial proportion of the variance
(8–21%) was accounted for by current ideation
status.
Although the pattern of specific neurocognitive
tests is somewhat different from that seen in other
studies of suicidal individuals, our findings are in
general accord with the concept of Ôexecutive
dysfunctionÕ associated with suicidality. For exam-
ple, Bartfai et al. (8) found that compared with
healthy men, or men with chronic pain syndromes,
male suicide attempters did significantly worse on
verbal and design fluency tests, but showed no
difference on the Uses of Objects Tests, WCST or
Mazes. Mark et al. (23) administered a modified
Stroop task (i.e. presentation of neutral or emo-
tional words) and found that compared with
controls, patients with suicide attempts showed
greater interference with emotional words related
to overdose themes. Keilp et al. (24) found that

Table 2. Performance on neuropsychological measures

Statistics*
Current suicidal No current suicidal
Measures ideation (n ¼ 25) mean (SD) ideation (n ¼ 28) mean (SD) B  R2 R2 change F P-value

WCST
No. of perseverative errorsà 14.4 (6.5) 8.6 (2.7) 5.72 0.34 0.23 16.30 <0.001
Failures to maintain setà 0.56 (0.77) 0.36 (0.91) 0.18 0.04 0.01 0.48 0.49
TMT
B minus A (secs) à 43.5 (26.1) 27.8 (13.8) 14.5 0.19 0.10 5.70 0.02
WISC – III Mazes subtest
Raw score§ 21.0 (3.8) 23.0 (3.5) )2.22 0.12 0.08 4.02 0.05
Fluency
Verbal (COWAT) no. of words generated§ 39.0 (11.6) 45.5 (10.4) )3.90 0.23 0.03 1.60 0.21
Non-verbal (FPT) no. of designs generated§ 31.2 (8.5) 33.0 (7.7) )0.56 0.17 0.001 0.06 0.81
SCWT
Interference– )1.5 (7.2) 2.3 (5.5) )3.19 0.16 0.05 2.90 0.10
BNT
Raw score§ 52.4 (5.0) 53.3 (4.0) 0.25 0.33 0.0007 0.05 0.83
ROCFC
Raw score§ 34.5 (1.8) 35.1 (1.2) )0.62 0.16 0.04 2.08 0.16

WCST, Wisconsin Card Sorting Test; TMT, Trail Making Test; WISC-III, Wechsler Intelligence Scale Test–third edition; COWAT, Controlled Oral Word Association Test; FPT, Five
Point Test; SCWT, Stroop Color Word Test; BNT, Boston Naming Test; ROCFC, Rey Osterrieth Complex Figure Copy.
*ANCOVA controlling for age, verbal IQ, and severity of depression (HRSD score) and history of previous attempt; d.f. ¼ 1, 48.
 The regression coefficient that represents the covariate-adjusted difference between those with current suicidal ideation (x ¼ 1) with those without current suicidal ideation
(x ¼ 0).
àA higher number indicates poorer performance.
§A lower number indicates poorer performance.
–A negative number indicates poorer performance.

298
 Executive functioning, depression, and suicidal ideation
attempters who made high lethal attempts could be
distinguished from those with a history of low
lethal attempts, non-attempters, and non-
depressed comparison subjects on measures of
verbal fluency, failure to maintain set on the
WCST, and on total recall in the Buschke Selective
Reminding Test.
In contrast, Ellis et al. (44) found no difference
on neuropsychological functioning of patients who
had recently attempted suicide and those with no
history of attempts. With the exception of an
interactive effect of age and group (recent attempt-
ers vs. non-attempters), King et al. (45) found
virtually no differences among elderly depressed in-
patients on a range of neuropsychological tasks. In
both these studies however, suicide status was
based on a history of suicide attempts and current
suicidal ideation was not assessed. It is possible
that following an attempt many patients are no
longer acutely suicidal. In our study we based
suicide status on the presence of current suicidal
ideation and controlled for a history of prior
suicide attempts. We believe cognitive rigidity is
more likely to be reflected in current thinking, i.e. a
suicidal mental state, than in past attempts, no
matter how recent.
Our results, taken together with those of other
studies, suggest that a mental inflexibility may
underlie suicidal thinking and the Ôexecutive decis-
ionÕ to commit suicide. Both the WCST and trails
B minus A tasks assess a subject’s ability to shift
cognitive set and to change a response pattern
based on environmental cues and contingencies.
Likewise, poor performance on the Mazes subtest
of the WISC-III suggests a cognitive rigidity that
involves a failure to develop appropriate strategies
within time limits. Although our group compari-
sons for verbal fluency were not statistically
significant, the directionality of the finding (suici-
dal subjects had poorer performance) together with
the Bartfai et al. (8) and Keilp et al. (24) studies,
suggest suicidal subjects may have difficulty gener-
ating alternative solutions to problems. Likewise,
the directionality of our findings on Stroop Inter-
ference (suicidal subjects had poorer performance),
along with the findings of Mark et al. (23), suggest
that suicidal subjects may have difficulties in
shifting perceptual set given changing demands
and may also have poor inhibitory control. Acutely
suicidal individuals appear to lack the cognitive
flexibility needed to generate new solutions or shift
among alternative strategies. In effect, they become
ÔstuckÕ on suicide or to use Shneidman’s (1) more
poetic term, have a Ôtunnel visionÕ.
Neurocognitive evidence of diminished execu-
tive functioning among suicidal individuals com-
plement those of postmortem studies which have
also suggested that there are serotonergic and
alpha-adrenergic binding changes in the frontal
cortices (in particular the ventrolateral prefrontal
cortex) of suicides compared with those of non-
suicidal controls. Postmortem studies of individ-
uals who had committed suicide, in effect, come
closest to ÔcapturingÕ an individual’s brain state at
the time of suicide, i.e. presumably when he or she
was thinking of suicide. The poorer performance
of our suicidal subjects is probably not part of a
diffuse, global brain dysfunction as suicidal sub-
jects performed nearly identically as non-suicidal
subjects on measures that are predominantly Ônon-
frontalÕ, i.e. the BNT and the Rey Copy Condi-
tion.
Studies of past attempters and non-attempters
would seem to suggest that performance differences
in neurocognitive functioning are either traits or at
least long-lasting cognitive ÔstylesÕ, as these studies
assessed the neurocognitive function of attempters
weeks or even months after the individual’s
attempts. These studies did not refer to current
suicidal ideation at the time of testing. Our study
design does not permit us to assess conclusively
whether the cognitive rigidity that we observed in
the suicide ideators is a state phenomenon or a
trait. However, it should be noted that our two
groups of ideators and non-ideators had about
equal numbers of persons with past suicide
attempts. Thus, our finding of group differences
among current ideators and current non-ideators
suggests that the cognitive rigidity may be tempor-
ary and not a persistent characteristic or cognitive
style in some individuals. Moreover, Perrah and
Wichman (46) found no differences in executive
measures that assess cognitive flexibility and set
shifting between past attempters and non-attempt-
ers. Past attempters were also less rigid than recent
attempters of other studies (47). Longitudinal
studies in which neuropsychological functioning
can be assessed repetitively in different stages of the
illness and studies of high-risk relatives are needed
to resolve whether cognitive rigidity of suicidal
thinkers is a state, trait, or even a ÔscarÕ that follows
the initial attempt.
Several limitations warrant comment. We did
not measure personality traits or assess personality
disorders that influence cognitive style and there-
fore might correlate with some neuropsychological
measures. However, the suicidal and non-suicidal
groups did not differ on a measure of impulsive-
ness. For ethical reasons we could not test severely
depressed suicidal individuals off medications;
however, it should be noted that the suicidal and
non-suicidal group did not differ on the type of
299
Marzuk et al.
medications they were taking at the time of testing.
Moreover, patients who were taking medications
known to influence neuropsychological functioning
such as tertiary amine tricyclic antidepressants,
older generation antipsychotics, and lithium were
excluded. In addition, the person who administered
the neurocognitive tests was not blind to the
subjectsÕ suicidality status, although this is not
likely to introduce a marked bias. Our findings
may not generalize to persons who have milder
levels of depression or to those who have psychi-
atric disorders that are associated with suicide risk
other than depression.
The development of neurocognitive probes in the
study of suicidal behavior may prove useful in
neuroimaging investigations that may begin to
elucidate the neural circuitry of suicidal mental
states. Improved understanding of the neurocog-
nitive impairments that may exist during suicidal
mental states will be critical to the development of
effective ÔneurocognitiveÕ treatments that are spe-
cifically designed to reduce suicidal behavior. It
will also be useful to see whether neurocognitive
models of suicidal mental states apply to other
groups at high risk for suicide such as those with
substance abuse, schizophrenia, or personality
disorders.
Acknowledgements
Supported by the Nancy Pritzker Network on Depression and
the Reader’s Digest Foundation, New York Community Trust.
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