Journal of Affective Disorders 225 (2018) 357–364

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

ERP investigation of attentional disengagement from suicide-relevant T

information in patients with major depressive disorder
⁎ ⁎⁎
Seung Yeon Baika,b, Minkyung Jeonga, Hyang Sook Kima, , Seung-Hwan Leeb,c,
a
Department of Psychology, Sogang University, Seoul, Republic of Korea
b
Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Republic of Korea
c
Department of Psychiatry, Inje University Ilsan Paik Hospital, Ilsan, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Previous studies suggest the presence of attentional bias towards suicide-relevant information in
Suicidal behavior suicidal individuals. However, the findings are limited by their reliance on behavioral measures. This study
Attentional bias investigates the role of difficulty in disengaging attention from suicide-relevant stimuli using the P300 com-
Attentional disengagement ponent of event-related potentials (ERPs).
Major depressive disorder
Methods: Forty-four adults with Major Depressive Disorder (MDD) were administered the spatial cueing task
Acquired capability for suicide
using suicide-relevant and negatively-valenced words as cue stimuli. Disengagement difficulty was measured
using reaction time and P300 during invalid trials.
Results: P300 amplitudes at Pz were higher in suicide-relevant compared to negatively-valenced word condition
on invalid trials for participants with low rates of suicidal behavior. However, no such difference was found
among participants with high rates of suicidal behavior. P300 amplitudes for suicide-relevant word condition
were negatively correlated with “lifetime suicide ideation and attempt” at Pz. No significant results were found
for the reaction time data, indicating that the ERP may be more sensitive in capturing the attentional disen-
gagement effect.
Limitations: The groups were divided according to Suicidal Behaviors Questionnaire-Revised (SBQ-R) total score.
Neutral stimulus was not included as cue stimuli. Most participants were under medication during the experi-
ment.
Conclusions: Our results indicate that patients with MDD and low rates of suicidal behavior show difficulty in
disengaging attention from suicide-relevant stimuli. We suggest that suicide-specific disengagement difficulties
may be related to recentness of suicide attempt and that acquired capability for suicide may contribute to
reduced disengagement difficulties.

1. Introduction One of the main predictors of suicide is depression, the most

Every year, over 800,000 people die by suicide and about 20 times
more people attempt suicide worldwide (World Health Organization,
2014). Global suicide rates have increased 60% in the last 45 years and
are expected to increase continuously (WHO, 2014). In particular,
South Korea has the highest suicide rate among the members of the
Organization for Economic Cooperation and Development (OECD,
2013), an international organization composed of 35 member countries
to collaborate for improvements in global economy and its well-being
(OECD, 2016). Suicide is a serious and prevalent health concern, and it
demands more empirical attention to enhance the understanding of its
causes and risk factors.
common mental disorder suffered by those who commit suicide
(Bertolote et al., 2003; Lejoyeux et al., 1993). However, not every in-
dividuals with depression commits suicide, and vice versa. Therefore,
this study focuses on investigating the vulnerability to suicidal beha-
viors among the group of individuals with major depression.
Cognitive theories of suicide have suggested that the attentional
bias (i.e., selectively shifting attention towards or away from a specific
type of stimulus (Macleod et al., 1986; Seehuus, 2015)) towards sui-
cide-relevant information can be interpreted as a cognitive vulner-
ability for suicide. Wenzel and Beck (2008) proposed that this bias can
lead to suicidal crisis when one encounters suicide-relevant cues during
the state of hopelessness. In such a situation, one can experience

⁎
Corresponding author.
⁎⁎
Corresponding author at: Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Juhwa-ro 170, Ilsanseo-Gu, Goyang 411-706, Republic of Korea.
E-mail addresses: hyangkim@sogang.ac.kr (H.S. Kim), lshpss@paik.ac.kr (S.-H. Lee).

http://dx.doi.org/10.1016/j.jad.2017.08.046
Received 28 December 2016; Received in revised form 28 June 2017; Accepted 14 August 2017
Available online 18 August 2017
0165-0327/ © 2017 Elsevier B.V. All rights reserved.
S.Y. Baik et al.
difficulty disengaging attention from suicidal cues and fixate attention
on suicide as the only means of escape. This cognitive model is sup-
ported by empirical research using the Stroop task. For instance, Becker
et al. (1999) and Williams and Broadbent (1986) found that suicide
attempters take longer reaction time (RT) to name the color of suicide-
relevant words compared to neutral, positive, or negative words. In
other words, suicide attempters have greater difficulty in inhibiting the
response of reading the suicide-relevant word, demonstrating atten-
tional bias, as opposed to other types of words (Cisler et al., 2009).
Moreover, Cha et al. (2010) found that suicide-specific attentional bias
is most evident among individuals with recent suicide attempts, and
predicts future suicide attempt over the next 6 months. Although these
findings support the presence of attentional bias in suicidal individuals,
a few studies have reported contradicting results. For instance, suicide
ideators and attempters did not show longer RT to suicide-relevant
words compared to negatively-valenced words (Chung and Jeglic,
2016). Richard-Devantoy et al. (2016) reported similar results as there
was no significant difference in RTs to suicide-related, positive, nega-
tive, and neutral words between suicide attempters and patient con-
trols.
Furthermore, the results of previous studies are limited by their
reliance on a single type of assessment method, the Stroop task. Stroop
task fails to identify the type of attention process that contributes to
suicide-relevant attentional bias (Cisler et al., 2009; MacLeod et al.,
1986). Specifically, attentional bias is often related to strongly engaging
attention to and/or showing difficulty in disengaging attention from a
certain stimuli (e.g., Koster et al., 2006; Stormark et al., 1995; Amir
et al., 2003). Previous studies have found that attentional bias towards
negative information in depressed individuals is associated with at-
tentional disengagement difficulties rather than facilitated engagement
(Koster et al., 2005a, 2005b; Sanchez et al., 2013; Sears et al., 2010).
Considering that suicide-relevant stimuli also contain negative valence,
these findings suggest that suicidal individuals among major depressive
disorder (MDD) patients may have attentional bias characterized by
disengagement difficulties. To our knowledge, no studies have in-
vestigated the role of attentional disengagement in suicidal individuals.
Studies that examine disengagement difficulties have used Posner's
(1980) spatial cueing task due to its ability to differentiate between
attentional engagement and disengagement processes (Derryberry and
Reed, 2002; Kessels et al., 2010; Koster et al., 2005a, 2005b). The
spatial cueing task examines the covert orienting of attention through
measuring the response to a target, which appears after presentation of
a cue (Posner, 1980). Attentional engagement and disengagement are
measured using RTs on valid (target presented in the same visual field
as a cue) and invalid trials (target presented in the opposite visual field
as a cue), respectively. Therefore, this study utilized the spatial cueing
task to investigate the role of attentional disengagement in individuals
with suicidal behavior. Since depression is related to attentional bias
towards negatively-valenced information (Peckham et al., 2010;
Sanchez et al., 2013), suicide-relevant and negatively-valenced words
(i.e., words with negative valence that is unrelated to suicide) are used
as cues; it was expected that the difference in task performance between
the two stimuli, which contain similar levels of negative valence, would
exhibit suicide-related attentional bias in patients with MDD at risk of
suicide.
To measure attentional disengagement, we used the method of
Event-Related Potentials (ERPs) in addition to behavioral measures. We
decided to add ERPs due to a limitation with behavioral measures,
where overt response (e.g., RT) reflects the output of multiple stages of
information processing (Luck, 2014). In fact, past studies have shown
that the RT measure of attentional bias has poor reliability (Brown
et al., 2014; Kappenman et al., 2014). Meanwhile, ERPs or small vol-
tage fluctuations that are time-locked to certain events (Jagaroo and
Santangelo, 2017) can measure specific cognitive processes using dif-
ferent components (Fichtenholtz et al., 2007). Also, ERPs provide a
millisecond level of temporal resolution (Luck, 2014), allowing the
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Journal of Affective Disorders 225 (2018) 357–364
investigation of the attention processes as soon as the event occurs
(Jagaroo and Santangelo, 2017).
Specifically, we assessed the P300, an ERP component that is ob-
served about 300 ms after a presentation of a task-relevant stimulus
(Andreassi, 2013). P300 has been widely used to measure attention
processes since its amplitude is proportional to the amount of atten-
tional resources engaged in processing a given stimulus (Johnson,
1988), and is unaffected by response selection and execution processes
(Crites et al., 1995). Studies using the spatial cueing task have reported
increases in P300 amplitude during target stimulus processing when it
was more difficult to disengage attention from the previously cued
stimuli (e.g., Kessels et al., 2010; Pollak and Tolley-Schell, 2003). Thus,
P300 could be used as an index of disengagement difficulties. P300
would provide a useful data and may be more sensitive to attention
effects than RT.
The present study aimed to examine the role of attentional disen-
gagement in suicidal individuals using RT and P300 while performing
the spatial cueing task. In this study, suicidal behavior is defined as the
overall suicide-related behavior, ranging from suicide ideation, plans,
to attempts. Our main hypothesis was that MDD patients with greater
level of suicidal behavior would demonstrate greater difficulty in dis-
engaging attention from suicide relevant words, compared to nega-
tively-valenced words. This would be depicted through longer RT and
higher P300 amplitude in suicide-relevant words compared to nega-
tively-valenced words during invalid trials for individuals with high
level of suicidal behavior. We predicted that there will be no differences
in RT or P300 between the two word stimuli for individuals with lower
level of suicidal behavior. We also hypothesized that suicide-related
attentional bias would be associated with attentional disengagement,
rather than engagement. Thus, we did not expect any differences in RT
and P300 amplitude between the two word stimuli in both groups
during valid trials.
2. Methods
2.1. Participants
Forty four patients diagnosed with MDD were recruited from Ilsan
Paik Hospital and community mental health centers in South Korea.
Participants were diagnosed according to the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5; American
Psychiatric Association, 2013) by board-certified psychiatrists. Partici-
pants were between ages of 20 and 65 and right-handed without any
history of psychotic symptoms or bipolar disorder. Participants with
severe medical disease, epilepsy, impaired vision, and brain injury were
excluded from this study. In addition, participants who attempted sui-
cide in the past 72 h or reported having the intention to commit suicide
within a week were excluded due to the risk of future suicide attempt.
The high suicidal behavior (n = 24) and low suicidal behavior
group (n = 20) differed in terms of the risk for suicide. The depression
and anxiety scores significantly differed between the two groups. This is
possibly due to the high correlations of depression and anxiety with
suicidal behavior (Apter et al., 1993; Minkoff et al., 1973). In addition,
67% and 5% of the participants had suicide attempt history in high and
low suicidal behavioral group, respectively. Lastly, 93.2% of the par-
ticipants were on antidepressant medication, such as es-citalopram,
desvenlafaxine, and venlafaxine.
All procedures were approved by the Institutional Review Board of
Inje University Ilsan Paik Hospital. Informed consent was obtained from
all participants prior to participation. Demographic information and
scores of psychological scales are presented in Table 2.
2.2. Psychological assessment
The severity of depression was assessed by the Korean version of
Beck Depression Inventory (BDI)-II, a commonly used self-reported
S.Y. Baik et al. Journal of Affective Disorders 225 (2018) 357–364

Table 1 2.3. Event-related potential paradigm

Means and standard deviations of frequency, suicide/death relevance, valence, and
arousal for suicide-relevant and negatively valenced words.
During the electroencephalography (EEG) session, participants wore
Suicide-relevant Negatively p-Value Effect size an electrode cap and were seated in front of a monitor. Participants
word (n = 20) valenced word (n (partial eta were asked to place a joystick (JTN-JTPC-108) where they found it
= 20) squared) comfortable and remain in the same position until the task ended. Then,
the participants were administered the spatial cueing task.
Mean SD Mean
The experiment was composed of 4 blocks of 60 trials each (total of
Frequency 87.75 147.75 86.25 .97 .97 .00 240 trials). The ratio of valid to invalid condition trials was 2:1, es-
suicide/death 4.96 .44 3.18 .00*** .00*** .72 tablished in a way to shorten the duration of the experiment regarding
relevance short attention span in depressive individuals (American Psychiatric
Valence −2.28 .85 −1.93 .10 .10 .07
Association, 2013). Typically, larger ratios are used to prevent the
Arousal 1.66 .76 1.49 .40 .40 .02
‘inhibition of return effect’, or the biased attention towards novel lo-
*** p < .001 cations. This effect is demonstrated by slowed RT on valid than invalid
trials (See Wright and Richard, 2000; Posner and Cohen, 1984). In
Table 2 order to ensure that the participants attend to the cue, we informed the
Means and standard deviations of participants’ characteristics in the low and high suicidal participants that they will be asked to recall the words after the ex-
behavior groups. periment. Greater RTs for invalid trials compared to valid trials would
indicate that the participants have successfully attended to the cued
Low suicidal behavior (n High suicidal behavior (n p-Value
= 20) = 24) location.
Word stimuli for each block were randomly selected with respect to
Mean SD Mean SD the distribution ratio. There were 20 words for each word type and each
word was presented with equal number of times from both left and
Age (years) 42.80 13.30 41.79 14.69 .78
Education 13.11 2.37 12.79 2.93 .71 right location. Targets were black squares (1 cm × 1 cm). For each
(years) trial, after a fixation period of 500 ms where a fixation point (+) was
Digit Span 25.30 7.58 24.54 6.51 .72 presented, word stimuli (22-point Courier New font) were randomly
BDI-II 14.25 11.57 32.88 14.77 .00 displayed for 700 ms on either left or right side of the screen. Then,
BAI 34.55 12.53 49.67 12.96 .00
300 ms of the blank screen was presented, followed by a target on ei-
BDI-II = Beck's Depression Inventory-II; BAI = Beck's Anxiety Inventory. ther side of the screen. Participants were asked to identify the position
of the target (left or right) using a joystick as quickly as possible. The
rating inventory that includes 21 items rated on a 4-point scale. The target remained on the screen until a response was recorded. After a
Korean version of BDI-II showed high Cronbach's alpha (α = .85) and 1000 ms interval, the next trial continued (Fig. 1).
test-retest reliability (r = .75) (Lee and Song, 1991). The internal For the participants to become familiar with the task, a practice trial
consistency for the current sample was α = .96. Anxiety was measured was conducted before the experimental session began. A break was
by the Korean version of Beck Anxiety Inventory (BAI), a self-reported given as long as the participant required after 2 blocks of the experi-
questionnaire composed of 21 items. BAI showed internal consistency ment. All participants were debriefed after the experiment.
and test-retest reliability of .93, and .84, respectively (Kwon, 1992).
The Cronbach's alpha for the current sample was α = .95. 2.4. Word stimuli
The current study employed the adapted Korean translation of the
Suicidal Behaviors Questionnaire-Revised (SBQ-R), which is a brief, The two set of stimuli contained similar levels of valence and
self-reported questionnaire that is often used to identify at-risk in- arousal but differed in suicidality. Specifically, we extracted lists of
dividuals as well as specific suicidal behaviors (Lee, 2009). SBQ-R is words that were suicide-related and negatively-valenced on the basis of
composed of 4 items that measure different dimensions of suicidality: 1) suicidal words adopted from previous studies (Cha et al., 2010; Lee
the lifetime suicide ideation and suicide attempt, 2) the frequency of et al., 2013), the contemporary Korean word frequency list at the Na-
suicidal ideation over the past 12 months, 3) the threat of suicidal tional Academy of the Korean language, and the Korean Affective Word
behavior, and 4) the likelihood of suicidal behavior by self-report list developed by Kim et al. (2010). Twenty one students in counseling
(Osman et al., 2001). SBQ-R was positively correlated with the Self- and clinical psychology master degree program at Sogang University
Harm Behavioral Questionnaire (r = .77) (Gutierrez et al., 2001) and were asked to list words that they perceived as suicide-relevant. Thirty
the Korean version of Beck Scale for Suicide Ideation (r = .62) (Lee and
Kwon, 2009), and negatively correlated with the Reasons for Living
Inventory (r = −.46) (Simon et al., 2007). The total scores of the SBQ-
R range from 3 to 18. The Cronbach's alpha for the adapted Korean
version of the SBQ-R was α = .93 and for the current sample, α = .84.
All items are listed in the supplement 1.
Participants were divided into two groups (high and low suicidal
behavior group) via a median split (10) on the basis of their SBQ-R
scores. Osman et al. (2001) found that the total cutoff score of eight
sensitively differentiate the clinical sample, including patients with
Schizophrenia, MDD, and Adjustment Disorder, into suicidal and non-
suicidal individuals. However, we evaluated that it could be in-
appropriate to apply the suggested cutoff score to the current sample
that consisted of patients with MDD, a disorder especially highly as-
sociated with suicide (Angst et al., 1999). Thus, we have divided the
groups based on a median split instead. Fig. 1. Sequence of events in the cueing task. Cue and target appear in the same visual
field for valid trials, and in the opposite visual field for invalid trials. Cue included sui-
cide-relevant and negatively-valenced words.

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S.Y. Baik et al. Journal of Affective Disorders 225 (2018) 357–364

words that appeared the most were selected accordingly. For nega- measures ANOVA with validity and word type as within-subject vari-
tively-valenced words, the researchers selected 30 words that have ables, and group as a between-subject variable. Age was included as a
matching syllables and frequency with 30 selected suicide-relevant covariate to control for its effect on RT (Der and Deary, 2005) and P300
words. Then, the 21 students rated the 60 words based on suicidality on amplitude (Juckel et al., 2012).
a 7-point Likert scale, and valence and arousal on a 9-point Likert scale ERP analysis was evaluated on the midline electrodes Fz, Cz, and Pz
(Table 1). Accordingly, 20 pairs of suicide-relevant and negatively-va- as P300 peak amplitudes and the related attentional processes generally
lenced words, which differed in suicidality but not in valence and appear largest at these sites (Johnson, 1993). The P300 peak amplitude
arousal, were selected (supplement 2). As a manipulation check, the increases in magnitude from frontal to parietal sites (Polich, 2007),
participants were instructed to rate suicide relevance, valence, and which was also found in this study, where Pz generally showed the
arousal for each word using the same rating scale after the experiment. largest peak amplitudes. P300 amplitude was defined as the maximum
positive peak amplitude between 250 and 500 ms after the target onset
2.5. Measures and analysis (Polich, 2007). 2 × 2 × 2 repeated measures ANOVA was conducted
for each electrode. Then, 2 (word type) × 2 (group) ANOVA was
2.5.1. Behavioral measures conducted at each level of validity type in the case of significant higher-
Difficulty in attentional disengagement was measured by the RT of order effects. If significant interaction was found, simple main effect
the performance on invalid trials. During invalid trials, the participant analysis with Bonferroni adjustments was performed. The above ana-
had to disengage attention from the cue stimuli to shift attention to the lysis was repeated with BDI and BAI scores as covariates in order to
target and respond. Therefore, longer RT reflects higher difficulty in control for the potential effect of depression and anxiety levels on the
disengaging attention from the cue. Errors consisted of inaccurate re- results.
sponses (e.g., pressing the right button when the target appeared on the In addition, correlation analyses were performed between the P300
left side) and omissions. Errors were analyzed to rule out a possible amplitudes of each condition and the SBQ-R items to examine the re-
speed/accuracy tradeoff. lationship between specific suicidal behaviors and attentional disen-
gagement. The bootstrap resampling (n = 5000) was used in order to
2.5.2. ERP measures correct multiple correlations (Dudoit et al., 2004).
EEG signals were recorded using a NeuroScan SynAmps 2 amplifier Lastly, paired samples t-tests were conducted to compare the par-
(Compumedics, El Paso, TX, USA) from 62 Ag/AgCl surface electrodes ticipants’ ratings on suicide relevance, valence, and arousal between the
mounted on a Quik-Cap (Compumedics, El Paso, TX, USA) according to two word stimuli.
the extended International 10–20 system. As a reference, a linked The significance level was set at p < 0.05 (two-tailed). Statistical
electrode pair was located at the left (M1) and right mastoid (M2), and analyses were performed using SPSS 21 (SPSS, Inc., Chicago, IL, USA).
the ground electrode was placed on the forehead. The vertical elec-
trooculogram (EOG) was recorded using bipolar electrodes: one located
above and one below the right eye. A horizontal EOG was recorded at 3. Results
the outer canthus of each eye. The impedance of the electrodes was
maintained at less than 5 kΩ. EEG data were recorded with a 0.1–100- 3.1. Behavioral measures
Hz bandpass filter at a sampling rate of 1,000 Hz, with 60 Hz noise
removed using a notch filter. Outliers were examined following Koster et al. (2004)'s suggestions.
The recorded EEG data were preprocessed using Scan 4.3 software As a result, RTs for inaccurate responses (0.8%), RTs shorter than
(Compumedics, El Paso, TX, USA). The gross artifacts, such as move- 150ms or longer than 1000ms (2.8%), and RTs more than 3 standard
ment artifacts, were rejected by visual inspection by a trained person deviation away from the individual's mean RT were removed from the
with no prior information regarding the data origin. Artifacts related to data (1.5%).
eye movement or blinks were removed using the mathematical proce- Repeated measures ANOVA for the error analysis revealed a sig-
dure implemented in the preprocessing software (Semlitsch et al., nificant main effect of validity, F(1, 42) = 4.52, p = .04. There were
1986). The data were filtered using a 0.1–30 Hz bandpass filter (zero greater number of inaccurate responses for invalid condition (M = .17,
phase-shift 24 dB/oct) and epoched from 100 ms pre-stimulus to SD = .51) than valid condition(M = .55, SD = 1.18). No other sig-
2000 ms post-stimulus. The epochs were subtracted from the average nificant main effects or interactions were found.
value of the pre-stimulus interval (−100 to 0 ms) for baseline correc- In addition, repeated measures ANOVA indicated that there was a
tion. If any remaining epochs contained significant physiological arti- significant main effect of validity, F(1, 42) = 5.05, p = .03.
facts (amplitude exceeding ± 75 μV) in any of the 62 electrode sites, Specifically, the mean RT of invalid trials was higher than that of valid
they were excluded from further analysis. Only artifact-free epochs trials. No further significant main effect or interactions were found
were averaged across trials and participants for ERP analysis. After the (Table 3).
artifact rejection, the number of epochs was not significantly different
between two groups. The number and percentages of remaining epochs
for the high and low suicidal behavior group were as follows: 1) suicide-
relevant words/valid trials (72.21 ± 5.58 [90.26%] vs. 73.57 ± 5.54
[91.96%], p = .42); 2) suicide-relevant words/invalid trials Table 3
Behavioral measures. Mean reaction time (ms) and standard deviations by validity, sui-
(36.33 ± 3.25 [90.83%] vs. 35.14 ± 4.00 [87.86%], p = .28); 3) ne- cidal behavior groups, and word type.
gatively-valenced words/valid trials (70.71 ± 5.77 [88.39%] vs.
73.24 ± 5.27 [91.56%], p = .13); 4) negatively-valenced words/in- Valid Invalid
valid trials (36.13 ± 3.23 [90.33%] vs. 36.00 ± 2.75 [90.00%], p =
Word Mean SD p-Value Mean SD p-Value
.89).
Low Suicidal Behavior
2.6. Statistical analysis Suicide-relevant 461.16 79.39 .28 474.66 93.18 .96
Negatively-valenced 465.55 79.40 474.90 97.73
High Suicidal Behavior
Behavioral data (RT and error) were analyzed with a 2 (validity
Suicide-relevant 452.06 111.04 .61 473.74 133.24 .23
type: valid vs. invalid) × 2 (word type: suicide-relevant vs. negatively- Negatively-valenced 450.61 113.38 480.47 132.73
valenced) × 2 (group: high vs. low suicidal behavior) repeated

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S.Y. Baik et al.
3.2. ERPs
Repeated measures ANOVA revealed a significant main effect of
validity for electrodes Pz, F(1, 41) = 5.35, p = .03. Specifically, the
mean P300 amplitude of invalid trials was higher than that of valid
trials (Fig. 2). There was a significant three-way interaction among
validity type, word type, and group at electrode Pz, F(1, 42) = 7.45, p
= .01. No main effects or interactions were found at other electrode
sites. Thus, all further analyses were restricted to electrode Pz.
Mixed ANOVA for the invalid condition at electrode Pz revealed a
significant interaction between word type and group, F(1, 42) = 7.50, p
= .01. Within group comparison for the low suicidal behavior group
revealed a higher P300 amplitude for the suicide-relevant word trials
than for the negatively-valenced words trials, F(1, 19) = 8.48, p = .01,
Bonferroni-corrected. No significant results were found for the high
suicidal behavior group (Fig. 3). For the valid condition, no main effect
or interaction was statistically significant (Supplement 3).
Furthermore, similar pattern of results was obtained when the
above analysis was repeated with BDI and BAI scores as covariates.
Analyses revealed that the low suicidal behavior group had higher P300
amplitude for the suicide-relevant word compared to negatively-va-
lenced word trials, F(1, 16) = 8.52, p = .01.
Lastly, we found a significant negative correlation between SBQ-R
item 1 (lifetime suicide ideation and attempt) and P300 amplitudes, r =
−.30, p = .05, CI [−.56, −.02], and a marginally significant negative
correlation between SBQ-R item 2 (frequency of suicide ideation over
12 months) and P300 amplitudes, r = −.28, p = .07, CI [−.51, −.02]
at electrode Pz in invalid/suicide-relevant words condition. There were
no significant correlations of SBQ-R item 3, r = −.13, p = .40, and
item 4, r = −.04, p = .82, with the P300 amplitudes in the corre-
sponding condition, as well as other conditions.1
3.3. Word ratings
Paired samples t-test revealed a significant difference in ratings on
suicide/death relevance between the suicide-relevant (M = 4.08, SD =
1.64) and the negatively-valenced words stimuli (M = 2.76, SD =
1.06), t = 6.38, p = .00. There were no significant differences between
word types for valence and arousal ratings.
These results manifest that the participants perceived similar levels
of valence and arousal but different level of suicidality for the two word
types. This demonstrates that the difference in P300 amplitudes be-
tween the word stimuli reflect the difference in suicidality rather than
valence or arousal.
4. Discussion
This study investigated whether suicidal behavior is related to dif-
ficulty in disengaging attention from suicide-related information by
analyzing RTs and P300 amplitude of the spatial cueing task. Our ERP
results suggest that MDD patients with high rates of suicidal behavior
have less difficulty in disengaging attention from suicide-relevant
words as opposed to negatively-valenced words. Specifically, the low
suicidal behavior group showed higher P300 amplitude in response to
suicide-relevant words compared to negatively-valenced words on in-
valid trials at Pz. For the high suicidal behavior group, there was no
significant difference in P300 amplitude between the two word types on
invalid trials. These results remained significant after the BDI and BAI
scores were entered as covariates, suggesting that the results can be
attributed to the level of suicidality rather than depression or anxiety
1
We have additionally performed a mixed-measures ANCOVA with SBQ-R as a con-
tinuous covariate. There was a marginally significant 3-way interaction between word,
trial type, and SBQ-R total score, F(1, 42) = 3.565, p = .06. For invalid trials, there was a
significant main effect of word type, F(1, 42) = 5.06, p = 03, and a significant interaction
between word type and SBQ-R total F(1, 42) = 3.479, p = .07.
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Journal of Affective Disorders 225 (2018) 357–364
Fig. 2. Mean peak P300 amplitudes at Pz site in valid and invalid trials. The horizontal
spacing exists to prevent overlap. *** p < .001.
severity. Furthermore, SBQ-R item 1 and item 2 had significant and
marginally significant correlations with P300 at Pz, respectively. These
results suggest that “lifetime suicide ideation and attempt” and “fre-
quency of suicidal ideation over the past year” may be dimensions of
suicidality that are especially associated with reduced difficulty in
disengaging attention from suicide-relevant information. The results
did not replicate at Fz and Cz sites. These findings are different from our
hypothesis that the high suicidal behavior group would have greater
disengagement difficulties.
As expected, there was no group difference in valid trials whereas a
significant interaction was found in invalid trials. This suggests that the
difference in suicide-related attentional bias is manifested in attentional
disengagement difficulties rather than enhanced attentional engage-
ment. In addition, both RT and P300 amplitude at Pz for invalid trials
were longer and higher, respectively, than those of valid trials. This
ensures that the participants have successfully attended to the word
stimuli with greater cognitive resource, warranting the use of P300
amplitude as an index of attentional disengagement as suggested by
previous studies (Kessels et al., 2010).
In general, the results do not support the existence of attentional
bias towards suicide-relevant stimuli in individuals with suicidal be-
havior. This could be due to lack of consensus on the definition of
“suicidal behavior.” For instance, Cha et al. (2010) recruited partici-
pants from the emergency department, and Becker et al. (1999) re-
cruited individuals who had attempted suicide within the past year.
This study included suicide attempters whose last suicide attempt
varied from a few months to 17 years ago, as well as suicide ideators
without suicide attempt history. Attentional bias towards suicide-re-
levant stimuli from previous studies could be related to acute state and
recentness of suicide attempt (Richard-Devantoy et al., 2016). Indeed,
attentional bias was reported to be the strongest among those who had
attempted suicide within the previous week (Cha et al., 2010; Williams
and Broadbent, 1986).
The high suicidal behavior group in this study may not have shown
suicide-specific disengagement difficulties due to other suicide-related
constructs such as fearlessness of death and liberal attitude towards
suicide. For instance, Joiner's Interpersonal Theory of Suicide (IPT)
emphasizes the role of reduced fear of death along with elevated pain
tolerance in lethal suicidal behavior (referred to as acquired capability
for suicide) (Van Orden et al., 2008). There is a general tendency to
show selective attention towards fear-related stimuli (Waters et al.,
2004). Therefore if one is fearless of death, one may not show difficulty
in disengaging attention from suicide-related information. Regarding
that the reduced fear of death is associated with suicide attempt history
and near death experiences (Smith et al., 2010; Van Orden et al., 2008;
Williams and Broadbent, 1986), high suicidal behavior participants in
our study may have exhibited reduced fear of death; most of the par-
ticipants in the high suicidal behavior group had suicide-attempt his-
tory as well as greater lifetime suicide ideation and behavior than the
S.Y. Baik et al. Journal of Affective Disorders 225 (2018) 357–364

Fig. 3. Grand averaged event-related potential (ERP) waveforms at Fz, Cz, Pz by group and condition for invalid trials. The bottom figure shows the topographical map at P300 for Pz
electrode by group and condition for invalid trials. (From left to right: low suicidal behavior group/suicide-relevant words, low suicidal behavior/negatively valenced words, high suicidal
behavior/suicide-relevant words, high suicidal behavior/negatively valenced words condition).

low suicidal behavior group. Similarly, several studies have discovered
that individuals with suicide ideation, attempt history, and future sui-
cide intent have more liberal and permissive attitude towards suicide
(Beautrais et al., 2004; Limbacher and Domino, 1986). Since the high
suicidal behavior group had higher scores on the SBQ-R items that as-
sess the above variables than the low suicidal behavior group, they
could have had a more liberal attitude towards suicide, leading to less
difficulty in disengaging attention from suicide-relevant stimuli. How-
ever, we did not make any assessments associated with the fear of death
or attitude towards suicide, and therefore the interpretation of the re-
sults still remains speculative. These factors are interesting topics to
explore in the future.
Lastly, findings in behavioral measures did not support the ERP
findings. The RT was similar between suicide-related and negatively-

362
S.Y. Baik et al.
valenced words trials for both groups. This suggests that the ERP may
be a more sensitive method than the RT in capturing the attentional
disengagement effect in individuals with suicidal behavior. To our
knowledge, this is the first study to use ERP in examining attentional
disengagement of suicidal individuals through Posner's spatial cueing
task. ERP studies in individuals with anxiety have reported ERP as a
more sensitive method for assessing attentional bias towards threat-
related stimuli (e.g., Bar-Haim et al., 2005; Kessels et al. 2010). Hence,
ERP may be an informative index for a study of attentional disen-
gagement in suicidal individuals. Because the interaction effect was
statistically significant only at Pz site, future studies are necessary to
confirm these results. This could be due to P300 amplitude typically
being reported as maximal and most reliable at this site (Kaustio et al.,
2002; Polich, 2007)
This study has several limitations. First, the groups were divided
according to the SBQ-R total score, a measure that encompasses dif-
ferent dimensions of suicidality. However, some researchers argue that
specific type of suicidal behavior represents a different
phenomenon (Beautrais, 2001; O'Carroll et al., 1996). If so, using the
SBQ-R total score could have affected our results, considering that
many previous studies have measured suicidality based on a specific
type of suicidal behavior, such as suicide attempt and ideation. Second,
neutral words were not included as cue stimuli. Although we have
deliberately selected suicide-relevant and negatively-valenced words,
the inclusion of neutral stimuli would have provided even more reliable
and ample results. Third, the results remained significant even after BDI
and BAI were included as covariates, but the results may have been
affected by depression and anxiety levels as they are closely associated
with suicidality. Yet, additional correlational analysis of depression and
anxiety levels with RT and P300 revealed no significant results. Fourth,
recent suicide attempt history (within 72 h) and the intent to commit
suicide within a week were part of the exclusion criteria for partici-
pation in this study. This was done for ethical reasons, as exposure to
suicide-relevant words had a possibility of harming such individuals.
However, acute state or recentness of suicide attempt could be a critical
factor in establishing the relationship between attentional bias and
suicidality. Finally, most of the participants were under medication.
Antidepressants could reduce P300 amplitude (d’Ardhuy et al., 1999),
yet there were no group differences on the type and amount of medi-
cation they were on.
In conclusion, the results suggest that patients with MDD and high
suicidal behavior exhibit less suicide-related attentional disengagement
difficulties than those with low suicidal behavior. Our results suggest
that more sophisticated suicide-related constructs, such as the recent-
ness of suicide attempt and acquired capability for suicide, should be
considered for future studies on attentional bias in individuals with
suicidal behavior.
Funding
This work was supported by a grant from the Korea Science and
Engineering Foundation (KOSEF), funded by the Korean government
(NRF-2015R1A2A2A01003564).
This work was supported by the National Research Foundation of
Korea Grant funded by the Korean Government (NRF-
2014S1A5A8018873).
None of the funding bodies influenced the project design, analyses,
and publications.
Acknowledgements
We thank M.S. Shim, S.K. Kim and Y.W. Kim for providing help in
analyzing the ERP data.
363
Journal of Affective Disorders 225 (2018) 357–364
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at http://dx.doi.org/10.1016/j.jad.2017.08.046.
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Seung Yeon Baik is a masters student in counseling and clinical psychology program at
Sogang University, and a researcher at Clinical emotion and cognition research labora-
tory. Her research interest involves mood disorders and self-concept.
Minkyung Jeong is a graduate of Sogang University, where she received a master's de-
gree in counseling and clinical psychology, and a former researcher at Clinical emotion
and cognition research laboratory. Her research interest includes suicide and its risk
factors.
Hyang Sook Kim is an associate professor at the department of psychology at Sogang
Univerisy in South Korea. Her research interest involves socio-cognitive mechanisms
underlying emotion and emotional disorders. Specifically, she has performed research on
dysfunctional emotion regulation, vulnerability to suicide, and cognitive control deficits
in depression and anxiety.
Seung-Hwan Lee, MD, and PhD, is a professor at the department of psychiatry at Inje
University, Ilsan Paik Hospital, and the director at Clinical emotion and cognition re-
search laboratory.